Maternal Infant Early Childhood Home Visiting
(MIECHV) Grant Program
Request for Proposal Materials
Grant Period: January 1, 2017 – September 30, 2019
Proposal Deadline: Friday, July 15, 2016
Division of Community and Family Health
Family Home Visiting Section
85 East 7th Place
P.O. Box 64882
St. Paul, Minnesota 55164-0882
651-201-4090
Maternal Infant Early Childhood Home Visiting (MIECHV) Grant Program Request for Proposals
January 1, 2017 – September 30, 2019
Information and Materials
May 2016
Community and Family Health Division
Family Home Visiting Section
Maternal Infant Early Childhood Home Visiting (MIECHV) Application
P. O. Box 64882
St. Paul, MN 55164-0882
Phone: 651-201-4090
http://www.health.state.mn.us/fhv/
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Table of Contents
Program Overview _________________________________________________________________ 5
Introduction ______________________________________________________________________________ 5
Definitions _______________________________________________________________________________ 6
Program Description _______________________________________________________________ 9
Background ______________________________________________________________________________ 9
Purpose of the Funding _____________________________________________________________________ 9
Models _________________________________________________________________________________ 10
MDH Responsibilities _____________________________________________________________________ 12
Available Funding ________________________________________________________________________ 12
Application Components ___________________________________________________________________ 13
Application Submission Guidance ____________________________________________________________ 13
Application Review and Award Process _______________________________________________________ 13
Program Summary ________________________________________________________________ 15
Project Narrative and Work Plan ____________________________________________________ 16
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Applicant Information ________________________________________________________________ 16
Linkages and Collaboration ____________________________________________________________ 16
Subcontracts _______________________________________________________________________ 17
Statement of Need: Proposed High Need Area and Families to be Served _______________________ 17
Continuous Quality Improvement (CQI) __________________________________________________ 17
Evaluation/Data Collection ____________________________________________________________ 18
Model Selection and Target Caseload ___________________________________________________ 19
Implementation Plan _________________________________________________________________ 20
Work Plan: Goals, Objectives, and Strategies ______________________________________________ 20
Need for Technical Assistance __________________________________________________________ 20
Budget Section ___________________________________________________________________ 21
Forms and Instructions ____________________________________________________________ 23
Form A: Grant Applicant Face Sheet __________________________________________________________
Form B: Grant Application Checklist __________________________________________________________
Form C: Home Visitor Staffing Plan __________________________________________________________
Form D: MIECHV Work Plan (2017 – 2019) ____________________________________________________
Budget Justification Instructions _____________________________________________________________
Form E: Budget Justification Form ___________________________________________________________
Budget Summary Instructions _______________________________________________________________
Form F: Budget Summary Form _____________________________________________________________
Indirect Cost Questionnaire Instructions ______________________________________________________
Form G: Indirect Cost Questionnaire _________________________________________________________
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Appendices ______________________________________________________________________ 39
Appendix A: Evidence-Based Home Visiting Model Descriptions ___________________________________ 40
Appendix B: Criteria for Scoring MIECHV Grant Applications ______________________________________ 44
Appendix C: MIECHV Work Plan Example – 2017-2019 Grant RFP __________________________________ 48
Appendix D: Expansion Information Form _____________________________________________________ 51
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Appendix E: Average MIECHV target caseload served by current grantees during Calendar Year 2015 _____ 52
Appendix F: High Risk Communities Identified in the Statewide Needs Assessment ____________________ 53
Appendix G: Minnesota Department of Health Grant Agreement Sample ____________________________ 54
Appendix H: Unallowable Uses of MDH Grant Funds ____________________________________________ 55
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Program Overview
Introduction
This Request for Proposal (RFP) document provides the forms and information needed to
complete the Maternal Infant Early Childhood Home Visiting (MIECHV) grant application. These
documents are available on the Minnesota Department of Health (MDH) Family Home Visiting
(FHV) website.
MDH will be available to provide consultation and guidance during the application process. All
questions or requests for assistance should be submitted to [email protected].
MDH Family Home Visiting staff should not be directedly contacted with questions or requests
for assistance related to the application. MDH staff will not be able to help with writing the
application.
MDH will maintain an “Answers to Grant Application Questions” link on the Family Home
Visiting (FHV) website. Questions and Answers will be updated regularly before the application
deadline.
There will be a technical assistance webinar to assist in writing the application. Applicants do
not need to attend the webinar to submit an application. However, if applicants have questions
about the grant application, they are encouraged to participate. The technical assistance
webinar will include:
 General information on the grant application
 General information on expectations related to the grant
 Information related to:
o Healthy Families America
o Nurse-Family Partnership
o Family Spirit
The webinar will use WebEx technology. Participants will need an internet connection,
computer, and a phone line to access the audio portion of the webinar. The technical assistance
webinar will be held on Thursday, May 26, 2016 from 1:30 to 3:30 p.m. To participate in the
webinar click here.
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Definitions
The following definitions are used throughout this application:
Adaptations to Evidence-Based Home Visiting Models – Acceptable adaptations to an evidencebased home visiting model includes changes to the model that have not been tested with
rigorous impact research but are determined by the Model Developer not to alter the core
components related to program impacts. The Model Developer or its designee and MDH must
approve any proposed adaptations.
Community Health Board (CHB)– The community health board as defined by Minnesota Statute
145A.02 is the legal governing authority for local public health in Minnesota. Community health
boards work with MDH in partnership to prevent diseases, protect against environmental
hazards, promote healthy behaviors and healthy communities, respond to disasters, ensure
access to health services, and assure an adequate local public health infrastructure.
Continuous Quality Improvement (CQI) – A systematic approach to specifying the processes
and outcomes of a program or set of practices through regular data collection and the
application of changes that may lead to improvements in performance.
Contiguous – Geographic areas sharing a common border.
Eligible Family – Under the MIECHV authorizing legislation, an eligible family is (a) a woman
who is pregnant, and the father of the child if the father is available; or (b) a parent or primary
caregiver of a child, including grandparents or other relatives of the child, and foster parents,
who are serving as the child’s primary caregiver from birth to kindergarten entry, and including
a noncustodial parent who has an ongoing relationship with and at times provides physical care
for the child.
Evidence-based Home Visiting Model – A home visitation model that has been in existence for
at least three years and is research-based, grounded in relevant empirically-based knowledge,
linked to program determined outcomes, associated with a national organization or institution
of higher education that has comprehensive home visitation program standards that ensure
high quality services delivery and continuous program improvement, and has demonstrated
significant, positive outcomes on indicators described in federal legislation, when evaluated
using a well-designed and rigorous randomized controlled research design and/or
quasiexperimental research design, and the results of which have been published in a peer
reviewed journal. Information on the three models eligible for funding under this application is
available in Appendix A.
Family Home Visiting Reporting and Evaluation System (FHVRES) – The data collection
system developed for the collection of Minnesota’s family home visiting data and MIECHV
performance measure data.
High Risk Community – Counties were identified as high risk by Minnesota’s needs assessment.
For this application, 46 high risk communities (counties) were identified. These high risk
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communities had a composite score of 13 or higher in the statewide needs assessment. See
Appendix F for more information about the statewide needs assessment and the 46 eligible
high risk communities.
High-Risk Priority Populations – Eligible populations identified in federal legislation as priority
for receipt of MIECHV-funded home visiting services, including: families who reside in
communities identified as at-risk communites in the statewide needs assessment; low-income
families; pregnant women who have not attained age 21; families with a history of substance
abuse or need for substance abuse treatment; families that have users of tobacco products in
the home; families that are or have children with low student achievement; families that
include individuals who are serving or formerly served in the Armed Forces, or who have had
multiple deployments outside of the United States.
Home Visiting Models– Programs or initiatives in which home visiting is a primary service
delivery strategy and in which services are offered on a voluntary basis to pregnant women,
expectant fathers, and parents and caregivers of children birth to kindergarten entry, targeting
MIECHV-adopted participant outcomes. For the purposes of this application, the following
home visiting models are eligible for funding: Healthy Families America, Nurse-Family
Partnership, and Family Spirit. Information on these models and the model developers is
available in Appendix A.
HRSA – Health Resources and Services Administration, U.S. Department of Health & Human
Services.
Informed Consent – Written permission from an individual to allow a government entity to
release the individual’s private data to another government or non-government entity or
person, or to use the individual’s private data within the entity in a different way (Minnesota
Statutes, section 13.05, subd. 4). A valid informed consent must be voluntary and not coerced,
be in writing, and explain why the use or release of data is necessary. Awarded applicants must
have a process that asks clients for their written informed consent to provide MDH with their
identifiable individual level data for the purpose of evaluating the MIECHV program. Awarded
applicants must inform their clients that the client’s decision regarding informed consent will
not in any way impact that family’s access to services.
Maintaining Fidelity of a Model – Providing services which meet the specified criteria and
components of the identified evidence-based home visiting model on an on-going basis.
MIECHV – Maternal, Infant, and Early Childhood Home Visiting.
National model developer – Entity responsible for the development of an identified evidencebased home visiting model.
Performance Measure Data – MIECHV performance reporting requirements include
demographic, service utilization, and federally-mandated benchmark area performance
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measures. All awarded applicants will be required to collect performance measure data on
participating families, and enter or upload the data into Minnesota’s Family Home Visiting
Reporting and Evaluation System (FHVRES) or other data collection system designated by MDH.
HRSA has recently revised the MIECHV performance reporting requirements, effective October
1, 2016. The required demographic and benchmark performance measures can be found on
this website HRSA 2017 Performance Measures .
Reflective Supervision – Reflective supervision is a distinctive form of competency-based
professional development that is provided to multidisciplinary early childhood home visitors
who are working to support very young children’s primary caregiving relationships. Reflective
supervision is a practice which acknowledges that very young children have unique
developmental and relational needs and that all early learning occurs in the context of
relationships. Reflective supervision is distinct from administrative supervision and clinical
supervision due to the shared exploration of the parallel process, that is, attention to all of the
relationships is important, including the relationships between home visitor and supervisor,
between home visitor and parent, and between parent and infant/toddler. Reflective
supervision supports professional and personal development of home visitors by attending to
the emotional content of their work and how reactions to the content affect their work. In
reflective supervision, there is often greater emphasis on the supervisor’s ability to listen and
wait, allowing the supervisee to discover solutions, concepts and perceptions on his/her own
without interruption from the supervisor.
Review Panel (RP) – A group of reviewers with backgrounds, knowledge and experience in
maternal and child health, home visiting or early childhood development selected by MDH to
evaluate and score submitted applications.
Target Caseload – The target caseload is the highest number of families (or households) that
could potentially be enrolled at any given time if the program were operating with a full
complement of hired and trained home visitiors. A trained home visitor must have at least 25
percent of his/her personnel costs (salary/wages including benefits) paid for with MIECHV
funding to have families served be counted as part of the target caseload. All members of one
family or household represent one caseload unit. Only active cases as defined by the evidencebased model may be counted toward the target caseload when reporting. The target caseload
is distinguished from the cumulative number of familes enrolled through the grant period.
Awarded applicants will identify a target caseload that will be achieved and maintained
throughout the grant agreement.
Title V – Enacted in 1935 as part of the federal Social Security Act, the Title V Maternal and
Child Health Program is designed to help states ensure the health of the Nation’s mothers,
women, children and youth, including children with special health care needs, and their
families.
Tribal Nation – A federally recognized American Indian tribe considered a sovereign nation.
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Program Description
Background
The Maternal Infant Early Childhood Home Visiting (MIECHV) funds originally authorized in the
federal Affordable Care Act (ACA) are administered through a partnership between the Health
Resources and Services Administration (HRSA) and the Administration for Children and Families
(ACF) of the U.S. Department of Health and Human Services. Funding allows states, territories
and tribal entities to develop and implement voluntary, evidence-based home visiting prorams
using models that are proven to improve child health and to be cost effective. These programs
improve maternal and child health, prevent child abuse and negelect, encourage positive
parenting, and promote child development and school readiness.
Purpose of the Funding
The purpose of this funding is for applicants to implement an evidence-based home visiting
model or to expand an existing evidence-based model based on identified community need.
The evidence-based home visiting models that can be chosen for implementation or expansion
are Nurse-Family Partnership (NFP), Healthy Families America (HFA), and Family Spirit (FS).
Community Health Boards or Tribal Nations serving families in identified high risk communities
in Minnesota are eligible applicants (Appendix F). The models are intended to be implemented
at the community level as part of a coordinated, integrated system of early childhood services.
Goals for the funding include:
 To strengthen and improve the state’s programs and activities carried out under Title V
 To improve coordination of services for high risk communities
 To identify and provide comprehensive services to improve outcomes for families who
reside in high risk communities
Funding is to support Community Health Boards and Tribal Nations in identified high risk
communities (a list of high risk communities is attached as Appendix F) to:
 Implement or expand an existing home visiting model(s)
o Nurse-Family Partnership (NFP)
o Healthy Families America (HFA)
o Family Spirit (FS)
 Serve eligible high-risk families
 Voluntarily enroll eligible families and maintain an identified target caseload
 Collect and report MIECHV performance measure data in the manner identified by the
MDH
 Maintain model fidelity for the chosen model(s)
 Participate in required trainings, meetings, continuous quality improvement and
evaluation activities including participation in communities of practice
 Collaborate with community partners to assure a coordinated, effective early childhood
system in the community and avoid duplication of services to families
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

Implement reflective practice supervision and infant mental health consultation
including entering into contracts with infant mental health consultants that will support
monthly team case conferencing, supervisor participation in monthly reflective practice
consultation and additional consultation as needed
Follow state guidance on development of program policies regarding enrollment,
disengagement, and re-enrollment of eligible families as well as other program policies
that may be identified by MDH for development and/or implementation
Counties not designated as a high risk community may collaborate with continguous high risk
designated counties. A justification for the selected contiguous multi-county area must be
provided and the designated area must be a viable and feasible area for providing services.
Priority will be given to applicants who propose to serve:
 Eligible families who reside in communities in need of such services, as identified in the
statewide needs assessment
 Low-income eligible families
 Eligible families with pregnant women who have not attained age 21
 Eligible families that have a history of child abuse or neglect or have had interactions
with child welfare services
 Eligible families that have a history of substance abuse or need substance abuse
treatment
 Eligible families that have users of tobacco products in the home
 Eligible families that are or have children with low student achievement
 Eligible families with children with developmental delays or disabilities
 Eligible families that include individuals who are serving or formerly served in the Armed
Forces, including such families that have members of the Armed Forces who have had
multiple deployments outside of the United States
Models
Below is a brief description of the models to be considered by applicants and to be funded by
this application.
Nurse-Family Partnership
NFP is an evidence-based, community health program that helps transform the lives of
vulnerable mothers pregnant with their first child. Each mother served by NFP is partnered with
a registered nurse early in her pregnancy and receives ongoing nurse home visits that continue
through her child’s second birthday. Independent research proves that communities benefit
from this relationship — every dollar invested in NFP can yield more than five dollars in return.
Nurse-Family Partnership Goals:
1. Improve pregnancy outcomes by helping women engage in preventive health practices,
including prenatal care from their healthcare providers, improving diets and reducing
use of cigarettes, alcohol and illegal substances;
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2. Improve child health and development by helping parents provide responsible and
competent care; and,
3. Improve the economic self-sufficiency of the family by helping parents develop a vision
for their own future, plan future pregnancies, continue their education and find work.
For information about becoming a new NFP replication site in Minnesota contact Chelsea
Pearsall, MA, Business Development Manager at [email protected]
For information about expanding a current NFP program in Minnesota contact Amy Goodhue,
PHN, Nurse Consultant at [email protected]
Healthy Families America
Healthy Families America (HFA) is an evidence-based intensive home visiting program designed
for parents facing challenges such as single parenthood; low income; childhood history of abuse
and other adverse child experiences; and current or previous issues related to substance abuse,
mental health issues, and/or domestic violence. Interactions between direct service providers
and families are relationship-based, designed to promote positive parent-child relationships
and healthy attachment, strength-based, family centered, culturally sensitive and reflective.
Individual HFA sites select the specific characteristics of families they plan to serve and
collaborate with community partners to reach these families. All families complete a Parent
Survey or similar assessment in order to determine the presence of various factors associated
with increased risk for child maltreatment or other adverse childhood experiences, as well as
identify family strengths and protective factors.
HFA aims to:
1. reduce child maltreatment;
2. improve parent-child interactions and children’s social-emotional well-being;
3. increase school readiness;
4. promote child physical health and development;
5. promote positive parenting;
6. promote family self-sufficiency;
7. increase access to primary care medical services and community services; and
8. decrease child injuries and emergency department use.
For information more information about HFA you can email the Implementaion Specialist for
Minnesota, Christi Peeples, at [email protected], or the National Director of
Implementation and Accreditation, Kathleen Strader, at [email protected].
Additional information about HFA is available at the HFA website.
Family Spirit
Family Spirit is an evidence-based family home visiting program designed by and for American
Indian pregnant women and families with children to age three. Family Spirit combines the use
of paraprofessionals, as well as nurses and other professionals, from the community as home
visitors and a culturally focused, strengths-based curriculum as a core strategy to support young
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families. Parents gain knowledge and skills to promote healthy development and positive
lifestyles for themselves and their children. This program has been developed, implemented,
and evaluated by the Johns Hopkins Center for American Indian Health in partnership with the
Navajo, White Mountain Apache, and San Carlos Apache Tribes since 1995.
Each agency implementing Family Spirit will complete a replication assessment with Johns
Hopkins and are free to determine their specific target audience and how the program will be
utilized in their community.
Family Spirit Program Goals:
1. To address the behavioral health disparities that pose the greatest challenges to Native
communities;
2. Increase parent knowledge and self-efficacy;
3. Address and decrease maternal depression;
4. Decrease substance use; and,
5. Address behavior problems in children with a unique curriculum.
For more information about Family Spirit you can email [email protected] or call Crystal Kee
(928-674-3911) or Jennifer Richards (928-283-8221). Additional information is available at the
Family Spirit website.
Additional information related to the models listed above, including initial costs and frequency
of visits, is included in Appendix A.
MDH Responsibilities
The MDH Family Home Visiting Section will:
1. Provide guidance and consultation as needed for the performance of the project and
maintaining fidelity to MIECHV and home visiting model requirements, including but not
limited to site visits, conference calls, and meetings or communities of practice.
2. Provide reporting requirements and tools for quarterly or annual reports.
3. Provide training and technical assistance on the MIECHV project, policies and
procedures, data collection procedures, forms, measures, continuous quality
improvement, and project evaluation.
4. Provide training, access, and technical assistance for the Family Home Visiting Reporting
and Evaluation System (FHVRES) or other designated data collection system.
Available Funding
Grant awards are for 33 months (1/1/17 through 9/30/19). MDH anticipates awarding 12
grants.
Current MIECHV grantees may only apply for funding to serve the average MIECHV target
caseload they reported to MDH in 2015. Appendix E contains information regarding the average
MIECHV target caseload served at each site during 2015 based on quarterly data submitted to
MDH.
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Applicants proposing to implement a model that has not been previously implemented by the
applicant may only apply for funding to serve up to 100 families for sites proposing NFP or
Family Spirit implementation and up to 96 families for sites proposing to implement HFA
utilizing the ratio of families to FTE home visitors recommended by the model developer as
follows:
 Nurse Family Partnership: 100 families with four FTE home visitors
 Healthy Families America: 48 families with two FTE home visitors
 Family Spirit: 25 families with one FTE home visitor
Applicants who have not been MIECHV grantees and who have implemented an evidencebased model or provided long term intensive home visiting may apply for the average number
of families that were served through the implemented model(s) or long term intensive home
visiting program in 2015.
Awarded applicants should not use funds from this funding opportunity to replace existing
funds for evidence-based home visiting programs in the applicant area. Awarded applicants are
expected to sustain current funding levels for existing evidence-based home visiting programs.
Application Components
See Form B, Grant Application Checklist for application components that should be submitted
with the application.
Application Submission Guidance
 Narrative portions of the application should be written in 12-point font, single spaced
with one-inch margins. The Work Plan (Form D) can be in 11 point font.
 All pages should be numbered consecutively.
 Click here to access a brief survey that must be completed by each applicant.
 Submit the entire application as one PDF document including the forms in the order
listed on Form B Grant Application Checklist Form by email to:
[email protected].
 The deadline for submission of applications is 4:00 p.m. on Friday, July 15, 2016. No
application will be accepted for consideration after this time.
Application Review and Award Process
This is a competitive grant application. Applications will be reviewed and scored according to
the Criteria for Scoring MIECHV Grant Applications (Appendix B). An applicant’s past
performance in implementing an evidence-based home visiting model and/or MIECHV grant
will be taken into consideration during the review process and in making final
recommendations for funding.
Reviewers may include staff from the MDH, developers of evidence-based home visiting models
or their staff, and staff from state agencies with experience related to early childhood or family
services, or individuals who are familiar with or who have provided home visiting services.
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Reviewers will be required to identify any conflicts of interest and will not review an application
if they have a direct relationship with the applicant.
Final funding recommendations will be based on the scores and comments from reviewers, past
performance of current funded MIECHV grantees and the high risk rankings identified in the
Minnesota needs assessment. When making awards, consideration will be given to distributing
funding throughout the state and/or regions and meeting the funding priorities identified in the
MIECHV legislation and MDH’s federal MIECHV application. It is anticipated that grant award
decisions will be made in September 2016. Applicants will be notified whether or not their
grant application was funded.
All materials submitted in response to this RFP will become property of the State and will
become public record in accordance with Minnesota Statutes, section 13.599 after the
evaluation process is completed. Pursuant to the statute, completion of the evaluation process
occurs when the government entity has completed negotiating the grant agreement with the
selected grantee. If the applicant submits information in response to this application that it
believes to be trade secret materials, as defined by the Minnesota Government Data Practices
Act, Minnesota Statute §13.37, the applicant must:
 Clearly mark all trade secret materials in its response at the time the application is
submitted;
 Include a statement with its application justifying the trade secret designation for each
item; and,
 Defend any action seeking release of the materials it believes to be trade secret, and
indemnify and hold harmless the State, its agents and employees, from any judgements or
damages awarded against the State in favor of the party requesting the materials, and any
and all costs connected with that defense. This indemnification survives the State’s award
of a grant contract. In submitting a response to this application, the applicant agrees that
this indemnification survives as long as the trade secret materials are in possession of the
State.
Applications are nonpublic until opened. Once opened, the name of the applicant, the address
of the applicant, and the amount the applicant requested is public. All other data in an
application is nonpublic data until completion of the evaluation process. After the evaluation
process has been completed, all data submitted by the applicant is public.
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Program Summary
Eligibility for Grant Funds
Total Funds Available
Grant Cycle
Grant Purpose
Application Guidance
Application Deadline
Community Health Boards, Tribal Nations
$5,500,000.00 for period January 1, 2017 – September 30, 2019
January 1, 2017 through September 30, 2019
To implement or expand an existing evidence-based home visting model(s).
 To participate in the technical assistance webinar on Thursday, May 26 from
1:30 – 3:30 p.m. click here. Participation is not required, but encouraged.
 Narrative portions should be in at least 12-point font with one-inch margins
 All pages should be numbered consecutively
 This brief survey must be completed by each applicant
 One PDF document submitted electronically to
[email protected]
All applications must be received electronically by MDH no later than 4:00 p.m. (CST)
on Friday, July 15, 2016.
Late applications will not be considered for review.
Applications Sent:
Beginning Grant
Agreement Date
Authority
Electronic Delivery Address: [email protected]
January 1, 2017, or date upon which all signatures to the agreement are obtained,
whichever is later.
The Minnesota Department of Health is the recipient of funding from the U. S.
Department of Health & Human Services to implement Minnesota’s Maternal Infant
and Early Childhood Home Visiting (MIECHV) Initiative (HRSA Grant No.
X10MC29483). This program is authorized under the Social Security Act, Title V,
Section 511 (42 USC 711), as amended by Section 2951 of the Patient Protection and
Affordable Care Act (Pub. L. No. 111-148).
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Project Narrative and Work Plan
The project narrative and work plan describes the applicant’s organization and what is intended
to be accomplished. To assist applicants, MDH has provided detailed instructions on what
information should be included and what grant reviewers will be reviewing in each application.
The Project Narrative is divided into distinct sections and should be submitted in the sequence
below:
A. Applicant Information
B. Linkages and Collaboration
C. Subcontracts
D. Statement of Need: Proposed High Need Area and Families to be Served
E. Continuous Quality Improvement
F. Evaluation/Data Collection
G. Model Selection and Target Caseload
H. Implementation Plan
I. Work Plan: Goals, Objectives, and Strategies (Form D)
J. Need for Technical Assistance
A. Applicant Information
Please keep this section to two or fewer pages.
If an applicant submits a joint application, the limit is two pages per organization. Applicants
should use 12-point font with one-inch margins for this portion.
1. Briefly summarize the applicant’s history related to family home visiting and if applicable,
experience implementing an evidence-based home visiting model.
2. Identify the local resources that are available to support or enhance the efforts of the
proposed application activities. Resources may include community achievements;
strengths; experience; commitment; staff; interagency experience or cooperation on
infrastructure tasks such as coordinated intake, screening and referral of families.
3. Briefly describe the support the applicant has related to this grant application including
applicant or governing body support.
4. Briefly describe the applicant’s history, success and capacity to bill for home visiting
services.
B. Linkages and Collaboration
Please keep this section to two or fewer pages.
1. Please describe the applicant’s collaboration with community partners related to planning
for or implementation of the evidence based model(s).
2. Please describe any proposed or current regional partnerships including discussions that
have occurred.
3. Discuss other home visiting programs (e.g. Early Head Start) in the community and how
applicant will assure non-duplication of home visiting services and coordination of home
visiting services in the community.
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4. Discuss how implementation or expansion of the evidence-based home visiting model(s)
will enhance and be integrated into the local early childhood system.
5. Describe the community advisory board that will be used to support the implementation
of the evidence-based home visiting model(s). Include information about members of the
community advisory board (community partners, funders, families who have received
home visiting, etc.), the role of the advisory board in the program, and frequency of
meetings.
C. Subcontracts
Please keep this section to one page or less.
All applicants must identify any subcontracts that will be required to carry out the duties stated
in the application in the Contractual Services line of the proposed Budget Section. The use of
subcontracts is subject to MDH review and may change based on final work plan and budget
negotiations with awarded applicants.
1. Describe services to be subcontracted.
2. Provide anticipated subcontractor/consultant’s name (if known) or selection process to be
used.
3. Estimate length of time services will be provided.
4. Total amount to be paid to subcontractor.
D. Statement of Need: Proposed High Need Area and Families to be Served
Please keep this section to two or fewer pages.
Please describe the need that the applicant is addressing in the community as the applicant
plans for implementation or expansion of the evidence-based home visiting model(s). Include
information about:
1. target population;
2. any needs assessment that was completed by the applicant independently or in
collaboration with other community partners;
3. identification of, rationale for proposing and feasibility to serve a county contiguous to
the high risk community and not identified as high risk for this application; and,
4. waiting list for sites considering expansion.
Include results or information from any planning process or tool such as the Zero to Three
Home Visiting Community Planning Tool that were used to determine the need and capacity for
the proposed implementation or expansion of the evidence-based home visiting model(s) in the
community.
E. Continuous Quality Improvement (CQI)
Please keep this section to two or fewer pages.
Applicants will be required to participate in a CQI learning collaborative and to develop their
own CQI projects related to implementation of their chosen model or connecting with the early
childhood system in their community. Meetings will be held quarterly via webinar/phone. Each
awarded applicant will be required to have a team of at least two to three people (including a
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supervisor and a home visitor) participate. Each awarded applicant will be required to actively
implement, track, and report on CQI projects related to home visiting.
1. Describe experience with quality assurance in general and any experience with the
quality assurance required by the proposed evidence-based home visiting model(s).
2. Describe any barriers or challenges to conducting CQI activities and any strategies for
addressing those barriers or challenges.
3. Describe how staff time will be budgeted and supported to focus on continuous
improvement.
4. Describe what data systems are available for use by the applicant for CQI purposes, and
how those data systems would be used to track progress, measure whether change
ideas resulted in improvement, identify the need for course corrections, and use data to
drive decision-making.
F. Evaluation/Data Collection
Please keep this section to two or fewer pages.
Awarded applicants will be required to submit data to FHVRES or other data collection systems
identified by MDH. Because of recent changes made by HRSA to the MIECHV performance
measures, MDH will need to implement changes to its current data collection system. It is
expected that there will be a six to twelve month transition period, during which alternative
methods of data submission may be required, such as the use of temporary data collection
forms or direct entry into a data collection system designated by MDH. Applicants should
allocate sufficient funds in their budget to support changes to the collection and reporting of
performance measure data, as well as staff time for alternative methods of data submission
during the transition period.
1. Describe the applicant’s ability to collect and report performance measure data as
required by federal, state, and model guidance. List any local data systems that will be
used for the collection of data.
2. If the applicant plans to make arrangements with another organization or government
entity to report performance measure data to MDH on the applicant’s behalf, please
state this and describe how the applicant will ensure that performance measure data
will be submitted as required. This may include duties in subcontracts as described in
Section C above.
3. Describe the applicant’s current frequency of data collection and analysis.
4. Describe the applicant’s experience ensuring the quality of data collection, and with
data management and analysis.
5. Describe the applicant’s data safety and security processes monitoring including
protection of data privacy and informed consent policies and procedures.
6. Describe any barriers or challenges to performance measure data collection and
reporting, and possible strategies for addressing those challenges.
18
G. Model Selection and Target Caseload
Please keep this section to two or fewer pages
1. Identify the model(s) the applicant proposes to implement or expand.
2. Describe how the selected model(s) address the high risk community and high risk
target population.
3. Describe how the proposed model(s) meets the needs or fills gaps of the community’s
home visiting continuum, including plans to ensure non-duplication of home visiting
services.
4. Describe the applicant’s capacity and readiness to implement the proposed model(s)
including capacity to hire and train staff.
5. Describe interactions with model developer(s) related to the proposed activities
outlined in this application, including any documents that may have been submitted to
a model developer as part of their recommended or required process for
implementation or expansion, and any feedback that was received from the model
developer.
6. Identify any challenges and risks of implementing the proposed model(s), any
challenges and risks in maintaining quality and fidelity to the model, any proposed
resolutions to those challenges and risks.
7. Identify the target caseload for each proposed evidence-based model that will be
achieved and maintained at 85% or higher under this proposed application, and how
the target caseload was determined. Note that only active cases as defined by the
evidence-based model may be counted toward the target caseload. If funded
previously with MIECHV funding, describe the success in achieving and maintaining the
target caseload for each year funded. CURRENT MIECHV GRANTEES: Please note the
average target caseload reported to MDH for 2015 provided in Appendix E. If you are
requesting to serve a target caseload in this application above the average reported to
MDH in 2015 or if you believe that your average caseload was greater than what is
included in Appendix E, please indicate the rationale for submitting a target caseload in
this application greater than the 2015 average. You should include information about
changes the applicant is making to their data collection and reporting submitted to
MDH to assure accurate data reporting. NON-MIECHV APPLICANTS CURRENTLY
IMPLEMENTING AN EVIDENCE-BASED MODEL OR PROVIDING LONG TERM, INTENSIVE
HOME VISITING: Applicants must provide the average number of families served
through an evidence-based model or applicant’s long term, intensive home visiting
program for 2015 and the number of FTEs serving those models and/or programs.
8. Describe challenges or barriers that may be or were experienced in achieving and
maintaining a minimum of 85% of the target caseload. Describe plans for addressing
and overcoming those challenges.
19
H. Implementation Plan
Please keep this section to two or fewer pages
1. Describe the plan for recruiting, hiring, training and retaining appropriate staff for
positions associated with the activities proposed in this application.
2. Evidence-based home visiting models identify the importance of a home visitor
implementing a model being at least .5 FTE in the model. This supports the home visitor
in implementing the model with fidelity and retaining families contributing to the overall
success of the program. Please complete Staffing Plan Form C. For each home visitor
that will be involved in implementing the activities outlined in this grant application,
include information about the total FTE the staff is involved in model implementation
whether funded by this proposed application or other funding sources.
3. Describe the plan for providing high quality reflective practice for all home visitors and
supervisors including infant mental health consultation and challenges and resolutions
that may be encountered in providing high quality reflective practice for all home
visitors and supervisors.
4. Describe the plan for identifying and recruiting high risk families to be served under this
application, including a plan for minimizing the attrition rate for participants.
5. Provide the estimated timeline to reach and maintain the target caseload.
6. Describe a plan for how the proposed model(s) will be implemented with fidelity to the
model, and any anticipated challenges to implementing the model(s) with fidelity,
including potential activities that would minimize those challenges.
7. Describe the process and commitment for development of a policy related to
enrollment, disengagement and re-enrollment, and non-duplication of services that
awarded applicants will be required to develop.
8. Describe the referral network that will be utilized to implement this program. Include
information both on resources that will refer families to the program and resources that
families will be referred to for needed services.
I. Work Plan: Goals, Objectives, and Strategies
Complete all of the work plan (Form D). Please limit the entire work plan to two or fewer pages.
The work plan has objectives that should not be changed. The dates included in the objectives
are suggestions and the dates may be changed according to the specific applicant’s timeline.
Note: If the application is approved and funded at the level requested, the Work Plan (Form D)
will be incorporated into the grant agreement between MDH and the grantee applicant as
contractor’s duties. A Work Plan must be completed according to directions so they can be
separated easily from the rest of the application. (See Appendix C for a Work Plan example.)
J. Need for Technical Assistance
Please keep this section to two or fewer pages.
Please describe any anticipated need for technical assistance or training and availability of
resources that can provide needed technical assistance and training. Applicants should identify
the anticipated number of staff that will need to participate in trainings sponsored by MDH and
identify the training needed, i.e. three staff need GGK training, two staff need NCAST.
20
Budget Section
Before writing the budget, consider the specific activity planned and the resources (staffing,
supplies, equipment, etc.) needed. Which resources are already available and what resources
need to be purchased? Which items will need to be replaced during the program (grant time
period)? When considering the skills needed to carry out the grant activity, including the
financial aspect of the grant, remember to include any training that will be needed for paid staff
or volunteer members.
Applicants proposing activities that involve the distribution of incentives for program
participation must include the costs for purchasing any incentives in the “Other” line of the
budget and follow the guidelines stated below.
Incentives can include gift cards or specific items. They may only be given to eligible
participants who:
 Attended a meeting/session/conference where the primary purpose of which is the
dissemination of grant program information.
 Completed a health screening or test;
 Participated in a public health study or survey;
 Participated in a one-time event designed to improve the public health or health care
systems by:
o Providing first-hand experience as a recipient of health care or public health services,
or
o as a child or adolescent model for trainings.
 A participant may not receive more than $50 worth of incentives per year. If using gift
cards, or a combination of gift cards and specific items, the total combined value may not
exceed $50.00.
 Incentives must be kept in a secure locked location at all times (ex: locked drawer, locked
cabinet).
 The applicant/grantee must track which client/participant received the incentive and the
dollar value of that incentive. Applicants/grantees must ensure data privacy when tracking
the distribution of incentives.
 Incentives must be distributed in the funding year in which they are purchased.
 In order for the expense of purchasing incentives to be reimbursable, the applicant must:
o address the use of incentives in the text of the RFP application
o account for the incentives in the “Other” line of the budget justification
o obtain MDH’s approval of the budget justification that includes the incentives
The applicant will need to complete one Budget Justification Form AND one Budget Summary
Form for each time period of applicant’s grant program listed below:
January 1, 2017 – September 30, 2017
October 1, 2017 – September 30, 2018
October 1, 2018 – September 30, 2019
21
Budget Justification Instructions and Form (Form E)
Please read the instructions for the Budget Justification Form carefully before completing the
Budget Justification Form. For each line item on the budget, provide a rationale and details
relative to how the budgeted cost items were calculated.
Each Budget Justification Form should provide the details of the applicant’s expenses and a
brief description of how they support the proposed grant activity for that time period. (The full
description of the purpose of each grant-funded position and the necessity of budgeted items
should appear in the Project Narrative.)
Budget Summary Instructions and Form (Form F)
Please read the instructions for the Budget Summary Form carefully before completing the
Budget Summary Form. Expenses in the line items should match the amounts listed in the line
items on the corresponding Budget Justification Form.
Each Budget Summary should be where the applicant provides the total expenses for the time
periods of the proposal by adding the expenses from the Budget Justification Form.
Indirect Cost Questionnaire (Form G)
Complete Form G. If the applicant will be using a Federally Negotiated Indirect Cost Rate,
include copy of the most recent Federally Negotiated Indirect Cost Rate with Form G.
Budget Scoring
The scoring of the Budget Section will be done using the Budget Justification Form and the
Budget Summary Form. If supplementary information is included, it will not be taken into
consideration for scoring purposes.
REMINDERS:
 Provide one Budget Justification Form AND one Budget Summary Form for each time
period listed below:
January 1, 2017 – September 30, 2017
October 1, 2017 – September 30, 2018
October 1, 2018 – September 30, 2019
 Total all lines and columns and check for mathematical accuracy.
 Make sure that the budget summary totals match the amount listed in number 1 on the
Grant Application Face Sheet (Form A).
22
Forms and Instructions
A. Grant Application Face Sheet Form
B. Grant Application Checklist Form
C. Home Visitor Staffing Plan
D. MIECHV Work Plan Form
E. Budget Justification Instructions & Form (one form for each time period listed on p. 22)
F. Budget Summary Instructions & Form (one form for each time period listed on p. 22)
G. Indirect Cost Questionnaire Form
23
Form A: Grant Applicant Face Sheet
General Applicant Information
Applicant’s Legal Name (do not use a “doing business as” name):
Applicant’s Business Address:
Applicant’s Minnesota Tax Identification Number:
Applicant’s Federal Tax Identification Number:
SWIFT Vendor ID Number (if you hae one):
Director of Applicant Agency
Name:
Business Address:
Phone Number:
Email:
Financial Contact, or Fiscal Agent, for this grant
Name of Financial Contact for this grant:
Name of Fiscal Agent for this grant, if applicable:
Phone Number:
Email:
Contact Person for this grant
Name:
Business Address:
Phone Number:
Email:
Requested Funding
Total Amount on Proposed Budget: $
I certify that the information contained above is true and accurate to the best of my knowledge; that I
have informed this agency’s governing board of the agency’s intent to apply for this grant; and, that I
have received approval from the governing board to submit this application on behalf of the agency.
Signature of Authorized Agent for Applicant
Date of signature
24
Form B: Grant Application Checklist
Use this checklist to ensure that you have included all the items for the grant application.
Have you included the following items?
Grant Applicant Face Sheet (Form A)
Clicked here to access a brief survey that must be completed by each applicant.
Grant Application Checklist (Form B)
Home Visitor Staffing Plan (Form C)
MIECHV Work Plan Form (Form D)
Budget Justification Form (Form E) (one for each time period listed on p. 22)
Budget Summary Form (Form F) (one for each time period listed on p. 22)
Indirect Cost Questionnaire (Form G)
APPLICATION DEADLINE:
Not later than 4:00 PM (CST) on Friday, July 15, 2016. Applications
received after this time will not be reviewed.
Electronic Delivery Address: [email protected]
25
Form C: Home Visitor Staffing Plan
Table C1 Home Visitor Staffing Plan
Home Visitor
FTE in Proposed
Application (Minimum
of .25 FTE)
FTE in Implementing
the Model in All
Applicant’s Programs
Funding for Home
Visitor (Bold or
Underscore Funding
Sources Used)
MIECHV
NFP State Funds
TANF
Title V/MCH Block
Other
MIECHV
NFP State Funds
TANF
Title V/MCH Block
Other
MIECHV
NFP State Funds
TANF
Title V/MCH Block
Other
MIECHV
NFP State Funds
TANF
Title V/MCH Block
Other
MIECHV
NFP State Funds
TANF
Title V/MCH Block
Other
MIECHV
NFP State Funds
TANF
Title V/MCH Block
Other
MIECHV
NFP State Funds
TANF
Title V/MCH Block
Other
26
Form D: MIECHV Work Plan (2017 – 2019)
Community Health Board or Tribal Nation:
Counties Included in Application:
Contact Person for Work Plan including name, email, and phone no.:
Date Submitted:
Target Caseload for Model to be Implemented:
_____ Healthy Families America
_______ Nurse-Family Partnership
_______ Family Spirit
Income: Report total income from Medicaid and other health insurance. Income can only be used for allowable program costs.
$_________________
Objectives
Activities
Quarterly Report
By January 1, 2017 develop a referral network
for incoming referrals to the program and
resources that the program will refer families
to based on need.
By February 1, 2017 identify members of a CQI
team and begin participation in the MIECHV
CQI Learning Collaborative.
By March 1, 2017 identify members and
purpose of the community advisory board and
implement utilization of the community
advisory board to provide guidance for
program implementation.
By March 1, 2017 a plan will be developed
identifying potential funding sources and next
steps to provide program sustainability.
By March 1, 2017 a plan will be developed and
implemented for how reflective practice
support will be provided for program
27
Objectives
Activities
Quarterly Report
supervisors and home visitors throughout the
grant period.
By April 15, 2017 and quarterly thereafter
submit quarterly reports to MDH related to
activities in this work plan.
By April 15, 2017 and monthly thereafter
submit data as outlined in the current version
of the Family Home Visiting Reporting
Guidance document for submission to MDH via
the designated data reporting system.
By May 1, 2017 develop policies as directed by
MDH. Policies will include but not be limited to
a policy assuring coordination of home visiting
programs in the community and nonduplication of home visiting services.
By January 1, 2017 for previously funded
MIECHV sites and May 1, 2017 for new MIECHV
sites achieve and maintain model approval,
affiliation or accreditation and retain model
fidelity through the grant period.
By June 1, 2017, a plan with community
partners will be developed that integrates
home visiting into the early childhood system
in the community and implement the plan
throughout the remainder of the grant period.
By May 1, 2017 for previously funded MIECHV
sites and December 31, 2017 for new MIECHV
sites achieve a full case load of families to be
served and maintain the caseload at 85%
during the grant period.
28
Budget Justification Instructions
Before the applicant begins writing the organization’s budget, consider the specific activity
planned and the resources needed to do it. What resources does the applicant need to be able
to plan for implementation or expansion of the proposed evidence-based home visiting
model(s)? Which items will need to be replaced during the grant program? When considering
the skills needed to carry out the activity, remember to include any training that will be needed
for staff.
Applicant will need to complete Budget Justification Form (Form E), one for each time period of
grant program listed on page 22. The Budget Summary Form (Form F) is where the applicant
will summarize each period of the grant Budget Justification Form by line item for each time
period of applicant’s grant proposal.
Each Budget Justification Form will provide the details of the applicant’s expenses and a brief
description of how they support the proposed grant activity for that budget period. (A full
description of how the applicant’s expenses support the proposed activities, including grantfunded positions, should appear in the Project Narrative.)
The categories listed below (salary/fringe, contractual services, travel, supplies/expenses,
other, and indirect) describe the costs that may be included in each category and correspond to
the sections in both the Budget Justification Form and the Budget Summary Form.
Salary and Fringe
For each proposed funded position, indicate the title, the full time equivalent (FTE) on this grant
(see example below), the expected rate of pay, and the total amount applicant expects to pay
the position for the year. Grant funds can be used for salary and fringe benefits for staff
members directly involved in applicant’s proposed activities.
Any salaries from the administrative, accounting, human resources, or IT support, MUST be
supported by some type of time tracking, in order to be included as a direct line expense. If
these salary expenses are not supported by time reporting documentation, then the expenses
must be included in the Indirect line and listed on the Indirect Cost Questionnaire.
Full time equivalent (FTE): The percentage of time a person will work on the selected evidencebased home visiting model(s). Each position that will work on this grant should show the
following information:
EXAMPLE:
Public Health Nurse:
$30.40/hourly rate
X 2,080/annual hours (or whatever your annual standard is)
$63,232 annual salary
Multiply annual salary by your agency’s fringe rate:
$63,232 annual salary
29
X 23% fringe rate (23% is an example, use applicant fringe rate)
$14,543 fringe amount
Now add the annual salary and the fringe amount together:
$63,232 annual salary
+$14,543 fringe
$77,775/annual salary and fringe total
Multiply the annual salary and fringe total by the FTE being charged to this grant:
$77,775 annual salary and fringe total
X .50 FTE assigned to grant
$38,888 total to be charged to grant for this position
Contractual Services
Applicants must identify any subcontracts that will occur as part of carrying out the duties of
this grant program as part of the Contractual Services budget line item in your proposed
budget. The use of contractual services is subject to State review and may change based on
final work plan and budget negotiations with selected grantees.
Applicant responses must include:
 Description of services to be contracted;
 Anticipated contractor/consultant’s name (if known) or selection process to be used;
 Length of time the services will be provided; and,
 Total amount to be paid to contractor.
Travel
List the expected travel costs for staff working on the grant, including mileage, hotel, and
meals. If project staff will travel during the course of their jobs or for attendance at educational
events, itemize the costs, frequency, and the nature of the travel. Grant funds cannot be used
for out-of-state travel without prior written approval from MDH. Minnesota will be considered
the home state for determining whether travel is out of state.
Community Health Board applicants:
 Budget for travel costs using the rates listed in the State of Minnesota’s Commissioner’s
Plan. Please reference the meal allowances rates listed there.
 Hotel/motel expenses should be reasonable and consistent with the facilities available.
Grantees are expected to exercise good judgement when incurring lodging expenses.
 Mileage will be reimbursed at the current IRS rate.
Tribal Nation applicants:
Budget for travel costs using the rates provided by the General Services Administration (GSA).
 Current lodging amounts and meal reimbursement rates vary depending on where in
Minnesota the travel occurs. Please reference the per diem rates listed there.
30



Hotel/motel expenses should be reasonable and consistent with the facilities available.
Grantees are expected to exercise good judgement when incurring lodging expenses.
A breakdown of the meals and incidental expenses can be found here.
Mileage will be reimbursed at the current IRS rate.
Supplies and Expenses
Briefly explain the expected costs for items and services the applicant will purchase to run the
program. These might include additional telephone equipment; postage; printing;
photocopying; office supplies; training materials; and equipment. Include the costs expected to
be incurred to ensure that community representatives, partners, or clients who are included in
the applicant’s process or program can participate fully. Examples of these costs are fees paid
to translators or interpreters. Grant funds may not be used to purchase any individual piece of
equipment that costs more than $5,000, or for major capital improvements to property.
Supplies and expenses should represent the appropriate fair share to the grant.
Other
Include in this section any expenses the applicant expects to have for other items that do not fit
in any other category. Some examples include, but are not limited to: staff training and
incentives. Grant funds cannot be used for capital purchases, permanent improvements; cash
assistance paid directly to individuals; or any cost not directly related to the grant. “Other”
expenses should represent the appropriate fair share to the grant.
Indirect Costs
Indirect costs are expenses of doing business that cannot be directly attributed to a specific
grant program or budget line item. These costs are often allocated across an entire agency and
may include administrative, executive and/or supervisory salaries and fringe, rent, facilities
maintenance, insurance premiums, etc.
The following are examples that could be included in indirect costs:
 Your department pays a general percentage to the city/county attorney’s office or the
sheriff’s department and these costs cannot be specifically attributed to an individual
grant.
 Your CHB or department pays a fee or percentage to the county/city human resources
department and these costs are not tied to a specific grant.
 The CHBs accounting system does not allow community health services (CHS)
administrator’s time to be directly attributed to specific grant activities.
In contrast, administrative costs are expenses not directly related to delivering grant objectives,
but necessary to support a particular grant program. These are items that, while general
expenses, can be attributed and appropriately tracked to specific awards. These items should
be included in the grantee budget as direct expenses in the appropriate lines of Salaries and
Fringe, Supplies, Contractual Services, or Other. They should not be included in the Indirect
line.
31
The following are examples of administrative costs that should be included in direct lines of the
budget and/or invoice:
 The CHS administrator’s time that can be tracked through time studies to a specific
grant (include in the Salary/Fringe line).
 A portion of secretarial/administrative support, accounting, human resources or IT
support staff expenses that can be tracked through time studies to a specific grant
(include in the Salary/Fringe line).
 Printing and supplies that your accounting system is able to track (for example through
copy codes) to a specific grant (include in the Supply line).
Any salary costs included in the Salary and Fringe line of the budget and/or invoice must be if
supported by proper time documentation. The total allowed for indirect costs can be charges
up to your federally approved indirect rate, or up to a maximum of 10%.
If the applicant will be using a Federally Negotiated Indirect Cost Rate, you will need to submit
with your application your most current federally approved indirect rate.
32
Form E: Budget Justification Form
Complete one form for each time period listed on page 22.
MDH Grant Program Name:
Applicant Agency:
Contact Person:
Phone Number:
Email Address:
Budget Period: ________ to ________
Revision # (MDH use only):
1. Salary and Fringe Benefits: For each proposed funded position, list the title, the full time
equivalent based on 2,080 hrs/year, the expected rate of pay, fringe rate (%), total annual
salary and fringe, and the percent of each position being charged to the grant. Failure to
provide the requested detail for each position may result in a delayed grant agreement.
Please refer back to page 29-30 for an example of how to show your salary/fringe expenses.
Justification:
REQUESTED
DOLLARS
Total Salary and Fringe $
2. Contractual Services: List the services applicant expects to contract out, the contractor’s or
consultant’s name, whether the contractor is non-profit or for-profit, the length of time the
services will be provided and the total amount expected to be paid. Supplies and travel of
contractor should be included, if applicable. Itemize equipment rented or leased for the
project.
Justification:
REQUESTED
DOLLARS
Total Contractual Services $
3. Travel: Explain applicants expected instate travel costs, including mileage, hotel and meals.
At a minimum, your organization must include the cost for at least one staff member to
attend two MDH-sponsored statewide or regional meetings. If program staff will travel,
itemize the costs, frequency and the nature of the travel.
Justification:
REQUESTED
DOLLARS
Total Travel $
33
4. Supplies and Expenses: Explain the expected costs for items and services the applicant will
purchase to run the program. Include telephone expenses that are part of this proposal; cell
phones and new telephone equipment to be purchased, if applicable. Estimate postage if
part of the project. List printing and copying costs necessary for the project (other than
occasional copying on an office copy machine). List office and program supplies and
expendable equipment such as training materials, curriculum and software. Generally
supplies include items that are consumed during the course of the project, equipment under
$5,000.
Justification:
REQUESTED
DOLLARS
Total Supplies and Expenses $
5. Other Expenses: Briefly describe any expenses that do not fit in any other category. Some
examples include, but are not limited to: staff training, and incentives.
Justification:
REQUESTED
DOLLARS
Total Other Expenses $
6. SUBTOTAL (Enter sum of lines 1 through 5):
$
7. Indirect Costs: Enter your proposed indirect cost rate below. In the box to the right, enter
the amount of indirect costs being requested. Indirect costs can be up to your federally
approved indirect rate, or up to a maximum of 10%, multiplied by the direct expenses in the
budget (line 6 of this form).
Indirect cost rate: _____%
8. TOTAL (sum of line 6 + line 7)
REQUESTED
DOLLARS
Total Indirect $
$
34
Budget Summary Instructions
This form should be used to show the total requested budget for the applicant’s proposed
grant-funded activities for each time period of the program. The budget should include funding
necessary in each category for each year of the grant. The total in each category should reflect
the total of that category from the corresponding Budget Justification Form.
Please enter zero (0) in the Total Proposed Amount column if you do not propose to expend
grant funds in a line item.
Enter the following items on the top portion of the Budget Summary Form:
 Name of MDH Grant Program for which the application is being submitted.
 Legal name of applicant agency applying for grant funds.
 Name of the contact person for questions regarding the budget being submitted.
 Telephone number for the contact person for the budget.
 Fax number of the contact person for the budget.
 E-mail address of the contact person for the budget.
1.
2.
3.
4.
5.
6.
7.
8.
Salary and Fringe: The total amount of grant funds that will be used during each time
period on page 12 to cover salary/fringe benefits (add the figures from the “Total Salary
and Fringe” box in all of the Budget Justification Forms).
Contractual Services: The total amount of grant funds the applicant plans to spend on
contractual services (add the figures from the “Total Contractual Services” box in all of the
Budget Justification Forms).
Travel: The total amount of grant funds that the applicant plans to spend on travel (add
the figures from the “Total Travel” box in all of the Budget Justification Forms).
Supplies and Expenses: The total amount of grant funds that the applicant plans to spend
on supplies and expenses (add the figures from the “Total Supplies and Expenses” box in
all of the Budget Justification Forms).
Other: The total amount of grant funds that the applicant plans to spend on items that are
not listed above (add the figures from the “Other Total” box in all of the Budget
Justification Forms).
Subtotal: The sum of lines 1 through 5. This figure should match the sum of the subtotals
on applicant’s Budget Justification Forms.
Indirect Costs: The total amount of grant funds that the applicant plans to spend for
indirect costs. Indirect costs can be up to an applicant’s federally approved indirect rate,
or up to a maximum of 10%, multiplied by the direct expenses in the budget (line 6 of this
form). This figure should match the sum of the indirect costs on your Budget Justification
Forms.
Total: The total in adding lines 6 and 7.
35
Form F: Budget Summary Form
Complete one form for each time period listed on page 22.
Name of MDH Grant Program:
Name of Applicant Agency:
Name of Contact Person for Budget:
Budget Period: _____________to ______________
Phone:
Fax:
E-mail:
Line Item
Total Proposed Amount
1) Salary and Fringe
2) Contractual Services
3) Travel
4) Supplies and Expenses
5) Other
6) Subtotal (sum of lines 1 through 5)
7) Indirect Costs (your federally approved rate,
or maximum of 10%, multiplied by line 6)
8) TOTAL (sum of line 6 + line 7)
36
Indirect Cost Questionnaire Instructions
Background
Applicants applying for a grant from the Minnesota Department of Health (MDH) may request
an indirect rate to cover costs that cannot be directly attributed to a specific grant program or
budget line item. This allowance for indirect costs are a portion of any grant awarded, not in
addition to the grant award.
It is important to know the difference between indirect costs and administrative costs before
completing the Indirect Cost Questionnaire Form. Please refer to pages 31-32 for more detailed
information on indirect costs.
Instructions
A. Fill in the applicant’s legal name.
B. Check the appropriate checkbox.
1. If the applicant is not going to request any indirect costs, the applicant should check the
first box and return the form as part of their application.
2. If the applicant has a federally approved indirect rate, the applicant should check the
second box, follow the instructions listed, and return the form as part of their
application.
3. If the applicant does not have a federal approved indirect rate, AND is planning to claim
indirect costs, the applicant should check the third box, fill in the rate being requested,
list the expenses being included in the indirect cost pool, and return the form as part of
their application. The maximum indirect rate an applicant can request from MDH is
10%.
37
Form G: Indirect Cost Questionnaire
Applicant’s Legal Name: _________________________________________
Program: 2017-2019 MIECHV Grant
Please check one of the three options below:
1. Not applicable
No charges to the grant program listed above are for indirect costs.
2. Federally Approved Indirect Cost Rate Agreement
A federally negotiated fixed rate is to be charged against all grant programs. A copy of
the federally approved Indirect Cost Rate Agreement covering the current federal fiscal
year is attached.
3. No federally approved indirect cost rate – requesting up to 10% maximum
Up to 10% of the direct expenses in the budget for the grant program listed above can
be used for indirect costs per CFR Part 200 - Uniform Administrative Requirements,
Costs Principles, and Audit Requirements for Federal Awards.
The applicant agency is requesting a rate of
% for the grant program listed above.
Per MDH Policy, the applicant must inform MDH of the types of costs included in the
applicant’s indirect costs. Please list below.
38
Appendices
Appendix A
Evidence-Based Home Visiting Model Description
Appendix B
Criteria for Scoring MIECHV Grant Applications
Appendix C
MIECHV Work Plan Example (2017-2019)
Appendix D
Expansion Information Form
Appendix E
Average MIECHV Target Caseload Servced by Current Grantees during
Calendar Year 2015
Appendix F
High Risk Communities Identired in the Statewide Needs Assessment
Appendix G
Link to MDH Grant Agreement Sample (This is sample language only.
Actual language may vary for any applicant awarded a grant.)
Appendix H
Unallowable Uses of MDH Grant Funds
39
Appendix A: Evidence-Based Home Visiting Model Descriptions
Theory
Target
population
Expected
outcomes
Family Spirit1
HFA2
NFP3
A child’s
development is
optimally achieved
through parents’
knowledge gained
across the domains
of physical,
cognitive, socialemotional, language
learning and selfhelp.
Young, Native
parents from
pregnancy to 3 years
post-partum
1) Increase parenting
knowledge and skills;
2) address maternal
psychosocial risks
that could interfere
with positive childrearing (i.e.
substance use
and/or depression);
3) promote optimal
physical, cognitive,
social- emotional
development for
children from 0 to 3
years; 4) prepare
children for early
Rooted in the belief
that early, nurturing
relationships are the
foundation for life-long,
healthy development.
Shaped by human
attachment, human
ecology and selfefficacy theories.
Designed for parents
facing challenges (i.e.
low income and/or
history of abuse).
1) Reduce child
maltreatment; 2)
increase utilization of
prenatal care; 3)
improve parent-child
interactions and school
readiness; 4) ensure
healthy child
development; 5)
promote positive
parenting; 6) promote
family self-sufficiency
and decrease
dependency on welfare
and other social
services; 7) increase
First-time, low-income
mothers and their
children.
1) Improve prenatal
health and outcomes;
2) improve child health
and development; and
3) improve families’
economic selfsufficiency and/or
maternal life course
development.
1
Adopted from model descriptions and criteria included on the John Hopkins Bloomberg School of Public Health website:
http://www.jhsph.edu/research/
centers-and-institutes/center-for-american-indian-health/Research_and_Programs/Current%20Projects/Family_Services/Family_Spirit.html
2 Adopted from model descriptions and criteria included on the federal MIECHV website:
http://mchb.hrsa.gov/programs/homevisiting/models.html
3
Ibid.
40
Program
components
Intensity
and length
Anticipated
Number of
Home Visits
Per Year Per
school success; 5)
ensure children get
recommended wellchild visits and
health care; 6) link
families to
community services
to address specific
needs; and 7)
promote parents’
and children’s life
skills and behavioral
outcomes across the
lifespan.
Consists of 63
lessons delivered by
Native American
paraprofessionals to
young Native parents
from pregnancy up
to the child’s 3rd
birthday.
Enrollment:
recommended start
at 28 weeks of
pregnancy. Services:
until child is 3 years.
Visits: Lessons can be
administered
sequentially or
independently,
depending on the
program structure
and participants’
needs.
access to primary care
medical services; and 8)
increase immunization
rates.
Visits are weekly for
the first 6 weeks of
prenatal enrollment,
then every other
week until the birth
of the child.
Pregnancy period –
visits weekly or every
other week until baby
is born.
1) Screenings and
assessments to
determine families
most likely to benefit
from services; and 2)
home visiting services.
Includes one-on-one
home visits between a
registered nurse
educated in the NFP
model and the client.
Enrollment: prenatally
or at birth. Services:
until child is 3 - 5 years.
Visits: weekly for the
first 6 months, followed
by a decreased
frequency depending
on participants’ needs
and progress toward
goals.
Enrollment: up to 28
weeks of pregnancy.
Services: until child is 2
years. Visits: Prenatal
visits occur once a
week for the first 4
weeks, then every
other week until the
baby is born.
Postpartum visits occur
weekly for the first 6
weeks and then every
other week until the
baby is 21 months.
From 21-24 months
visits are monthly.
Pregnancy period–
visits once a week for
first 4 weeks after
enrollment; then every
other week until the
baby is born.
41
Model
Fidelity
Costs
Associated
with Model
Participation
Infancy visits are
weekly for 6 weeks,
then every other
week until seven
months. Visits then
decrease to monthly
until the child turns
two when visits are
every other month.
Visit schedules are
flexible and can be
tailored to each
client as staff time
allows.
Tailored Training
Development and
Implementation
Affiliation Fee
(includes technical
and implementation
assistance and
support for
sustainability):
 $9,000 the
first year per
affiliate site.
 $3,000
annually
thereafter
Initial Site Training:
 $3,000 per
trainee
 $4,000 per
supervisor (at
least one
supervisor
required for
every 10
home visiting
staff).
After baby is born –
visits are offered
weekly until baby is 6
months and parents
are making progress
toward program goals.
Visits decrease to every
other week and as
parents meet criteria,
move to monthly.
Some families facing
greater challenges may
continue weekly visits
for a longer period of
time until they show
progress in meeting the
criteria.
HFA requires affiliation
as the first step
towards accreditation
followed by
accreditation which
happens between years
2 & 3.
Affiliation fee is payed
when an affiliation
application is
submitted: $500
Annual affiliation fees
are payed each year
until accreditation is
achieved:
 2016 Affiliates:
$4500 each year
 2017 Affiliates:
$5000 each year
 2018 Affiliates:
$5000 each year
(HFA has offered a
reduced affiliation rate
for programs in MN
that affiliate in 2016:
$2,025 for yr. one,
Infancy period- from
birth of the child to 12
months of age; visits
once a week for the
first 6 weeks; then
every other week
through 12 months of
age (27 visits
maximum)
Toddler phase- Visits
every other week from
13 – 20 months of age;
then once a month
from 21 – 24 months of
age (22 visits max)
The NFP program costs
approximately $4,800
per family per year to
fund and can range
from $3,500 to $6,500
per family per year.
Staff salaries are the
primary driver that
affects variability of
cost.
NFP Start-up Fee
$27,461 includes;
 initial support
to help agency
staff prepare to
implement the
program and
successfully
move through
the initial phase
of start-up,
 education
about
implementation
and access to
the NFP data
collection and
42



$1,800 for
new trainees
at an
affiliated site
$1,300 for
refresher
training for
staff
Sites may
choose to
send staff to
Albuquerque
for training,
additional
travel costs
for trainers
may be
incurred if
sites wish to
have on-site
training.
$3500 annually in
subsequent years.)
Once a site achieve
accreditation: annual
fees to maintain
accreditation are based
on program size:
Very small (up to 2.0
FTE) - $,1750
Average (2.1 – 15 FTE)
-$3,500
Accreditation
application fee=$250.
Fee for the peer
reviewer site visit is
$2,700 for 2 reviewers
for 3 days.
If training for
Integrated Strategies
Core for Home Visitors
or Parent Survey Core
is required outside of
what is available
through MDH, costs per
individual are $650 for
each 4 day training, and
an additional $215 for
the supervisor to
attend a required 5th
day. Manual is covered
in the cost of training.
reporting
system (ETO)
 incremental
program
support and
nurse
consultation
provided during
the first two
years of
implementation
Nurse HV Initial
Education - $4400
Nurse Education
Materials $559.
Supervisor Initial
Education - $5194.
43
Appendix B: Criteria for Scoring MIECHV Grant Applications
Procedures for assessing the technical merit of applications have been instituted to provide for
an objective review of applications and to assist the applicant in understanding the standards
against which each application will be judged. Critical indicators have been developed for each
review criterion to assist the applicant in presenting pertinent information related to that
criterion and to provide the reviewer with a standard for evaluation. Review criteria are
outlined below with specific detail and scoring points.
These criteria are the basis upon which the reviewers will evaluate the application. The entire
proposal will be considered during objective review. Review criteria are used to review and
rank applications.
Applicant Information (32 points)
1. Does the applicant describe their agency’s history related to home visiting and if
applicable their experience implementing an evidence-based home visiting model?
2. Does the applicant describe the local resources that are available to support or enhance
the efforts of the proposed application activities? Resources may include community
achievements; strengths; experience;commitment; staff; interagency experience or
cooperation on infrastructure tasks such as coordinated intake, screening and referral of
familes.
3. Does the applicant describe support they have received related to the application
including any governing board, advisory group or agency support?
4. Does the applicant describe in some detail their capacity to bill for home visiting services
for Medicaid recipients of home visiting?
Linkages and Collaboration (45 points)
1. Does the applicant describe their collaboration with community partners related to
planning for or implementation of the evidence-based model(s)? If applicable (a multisite collaboration), does the applicant discuss any regional collaborations?
2. Does the applicant describe other home visiting programs in their community (including
Early Head Start) and how the applicant will assure non-duplication of home visiting
services and coordination of home visiting services in the community such as
coordinated intakes, regular meetings to discuss referrals, community agreement on
clients to be served by home visiting programs, eligibility criteria for each community
home visiting program.
3. Does the applicant clearly describe the members of the community advisory board?
Does the community advisory board broadly represent the community, i.e. funders,
community partners, families who have received home visiting services? Is the role of
the community advisory board clearly defined including frequency of meetings?
Subcontracts (10 points)
If the applicant proposes to contract out services, does the applicant:
1. Describe the service to be contracted for;
2. Provide anticipated contractor information including name and selection process to be
used;
44
3. Length of time the services will be provided; and,
4. Total amount to be paid to the contractor?
Statement of Need: Proposed High Need Area and Families to be Served (36 points)
1. Has the applicant identified the community need that the applicant hopes to address
with the application and proposed activities?
2. Does the applicant include in their description of need:
a. A target population;
b. Any needs assessment that was completed by the applicant separately or in
collaboration with other community partners;
c. Identification of, rationale for proposing and feasibility to serve a county contiguous
to the high risk community and not identified as high risk for the application;
d. Waiting list for home visiting services especially for those sites considering
expansion or other information demonstrating need for expanded services?
3. Does the applicant include any results from a planning process or use of a tool such as
the Zero to Three Home Visiting Community Planning Tool to determine need and
capacity for the proposed implementation or expansion of the proposed evidence-based
home visiting model(s)?
Continuous Quality Improvement (27 points)
1. Does the applicant describe and appear to have an understanding of the quality
assurance/quality improvement requirements of the evidence-based model(s) proposed
to be implemented?
2. Does the applicant have an understanding of the barriers and challenges that may be
faced in conducting quality improvement activities? Does the applicant propose
resolutions to those challenges or overcoming barriers?
3. Does the applicant describe a plan and capacity to utilize data for quality improvement
activities?
Evaluation/Data Collection (30 points)
1. Does the applicant clearly describe the capacity to collect and report demographic,
service utilization, benchmark, and outcome data?
2. Is there a clear description of the applicant’s current activities and methods for data
collection and analysis including frequency of those activities?
3. Does the applicant clearly describe how they assure data quality and the applicant’s
data management and analysis experience? Do they provide examples of data analysis?
4. Does the applicant describe an informed consent process being in place? Does the
applicant describe policies or procedures related to maintaining data safety and
security?
5. Is the applicant able to describe barriers or challenges to collecting and reporting data?
Does the applicant suggest strategies they will use to overcome barriers or challenges?
Model(s) Selection and Target Caseload (56 points)
45
1. Does the applicant clearly describe how the selected evidence-based model(s) will
address the high risk community and the high risk target population selected by the
applicant?
2. Does the applicant identify the needs or gaps in the community’s home visiting
continuum and how the selected model(s) will address those needs or gaps?
3. Does the applicant describe a plan ensuring non-duplication of home visiting services in
the community? Does the plan support the delivery and non-duplication of home
visiting services in the community?
4. Is there a clear description of the applicant’s capacity and readiness to implement the
proposed model(s) including the capacity to hire, train and retain staff.
5. Has the applicant discussed the proposed activities with the model developer? Has the
applicant submitted any documents related to the proposed activities to the model
developer? Does the applicant describe any feedback received from the model
developer regarding proposed activities? Has the applicant addressed any feedback
received from the model developer?
6. Does the applicant describe the challenges and risks in implementing the proposed
model(s)? Does the applicant describe challenges to maintaining fidelity to the
model(s)? Are there proposed activities to address those barriers or risks?
7. Does the applicant include a target caseload? Does the applicant clearly describe how
the target caseload was selected? If previously funded by MIECHV, does the applicant
describe past experience in achieving and maintaining 85% of the target caseload? If the
applicant is requesting a target caseload greater than their 2015 average, does the
applicant include information about changes the applicant is making to their data
collection and reporting submitted to MDH to assure accurate data reporting in the
future and explain their rationale for the higher than 2015 target caseload?
8. Does the applicant describe challenges or barriers to achieving 85% of target caseload
and activities to be implemented to address those challenges or barriers?
Implementation Plan (72 points)
1. Is there a clear plan for recruiting, hiring, training and retaining appropriate staff for the
positions associated with proposed activities?
2. Does the applicant clearly identify that every home visitor works at least .5 FTE
implementing the model? If the home visitor is less than .5 FTE on the proposed
application funding source is it clear that the home visitor is funded by other funding
streams that would allow for the home visitor to be at least .5 FTE implementing the
model?
3. Does the applicant describe how high quality reflective practice including infant mental
health consultation for all home visitors and supervisors will be provided? Is there a
description of challenges that may be faced in providing reflective practice and infant
mental health consultation? Are there suggested activities that will help address those
challenges?
4. Does the applicant describe a clear plan for identifying and recruiting high risk families?
Does the applicant describe how they will minimize attrition of families? Does the
applicant appear to have the capacity and linkages needed to recruit families?
46
5. Is the timeline to achieve and maintain the target caseload feasible?
6. Does the applicant describe the capacity and a plan to maintain model(s) fidelity? Does
the applicant demonstrate an understanding of possible barriers to implementing a
model with fidelity? Are there strategies described that would address challenges or
barriers to implementing a model with fidelity including resources that may be needed?
7. Does the applicant demonstrate a commitment to development of a policy related to
enrollment, disengagement and re-enrollment including non-duplication of services?
8. Is there a referral network described by the applicant? Does the referral network
include entities that may refer to the applicant? Are there clear relationships with those
entities? Does the applicant provide information on entities they may refer clients to
and demonstrate an understanding of the need of clients that may be served by the
applicant?
Work Plan: Goals, Objectives, and Strategies (63 points)
1. Do the activities outlined in the work plan demonstrate the applicant’s capacity to
report data quarterly?
2. Will the proposed activities support the applicant in submitting quarterly reports
regarding activities completed?
3. Will the proposed activities support the applicant in being able to identify members and
the purpose of the community advisory board to provide guidance related to program
implementation?
4. Will the proposed activities result in the applicant being able to develop a policy
assuring coordination of home visiting programs in the community and non-duplication
of home visiting services?
5. Will the proposed activities support the applicant in achieving and maintaining at least
85% of the target caseload during the grant period?
6. Will the proposed activities result in the applicant being able to achieve and maintain
model approval, affiliation or accreditation and retain model fidelity throughout the
grant period?
7. Will the proposed activities achieve and implement a plan between the applicant and
community partners to integrate home visiting into the early childhood system in the
community?
Need for Technical Assistance (9 points)
Does the applicant clearly describe anticipated need for technical assistance or training and
resources that may be available?
Budget (48 points)
1. Are the budget forms complete?
2. Do the amounts in the Budget Summary and the Budget Justification match?
3. Is the information contained in the budget and work plan consistent? Will the budget
support the activities identified in the work plan?
4. Are the projected costs reasonable, cost-effective and sufficient to accomplish the
proposed activities?
47
Appendix C: MIECHV Work Plan Example – 2017-2019 Grant RFP
Community Health Board or Tribal Nation:
Counties Included in Application:
Contact Person for Work Plan including name, email, and phone no.:
Date Submitted:
Target Caseload for Model to be Implemented:
_____ Healthy Families America
_______ Nurse-Family Partnership
Objectives
By January 1, 2017 develop a referral network
for incoming referrals to the program and
resources that the program will refer families
to based on need.
By February 1, 2017 identify members of a CQI
team and begin participation in the MIECHV
CQI Learning Collaborative.
By March 1, 2017 identify members and
purpose of the community advisory board and
implement utilization of the community
advisory board to provide guidance for
program implementation.
By March 1, 2017 a plan will be developed
identifying potential funding sources and next
steps to provide program sustainability.
_______ Family Spirit
Activities
 Identify priority partners that are potential
referral sources of the target population.
 Identify resources in the community that can
provide additional support services to families.
 Develop plans for outreach activities to priority
partners and community resources.
 Formal MOU agreements executed with priority
partners.
 Identify members of a CQI team.
 Participate in MIECHV CQI Learning Collaborative
meetings.
 Identify CQI projects related to implementation
of their chosen model or connecting with the
early childhood system in the community.
 Implement, track, and report on CQI projects.
 Adhering to model guidelines, define the role
and purpose of the community advisory board.
 Identify and invite partners to participate on the
community advisory board.
 Schedule a meeting for the community advisory
board and regularly scheduled meetings.
 Seek/maximize Medicaid reimbursement for
services provided to eligible families.
 Seek technical assistance from MDH or DHS for
reimbursement challenges.
 Assign staff to review and address any errors or
missed reimbursement opportunities.
 Pursue other funding/grant opportunities to
support home visiting programs to at-risk
families.
 Engage key stakeholders in support of program.
48
Objectives
By March 1, 2017 a plan will be developed and
implemented for how reflective practice
support will be provided for program
supervisors and home visitors throughout the
grant period.
Activities
 Conduct monthly team reflective supervision
with licensed mental health provider or skilled
infant mental health consultant. (Level III or IV).
 Supervisor will receive monthly 1:1 reflective
supervision with an individual skilled in RP
consultation and provide reflective supervision to
the home visitors per the model expectations.
 Supervisor provides joint home visits with each
home visitor per model expectation.
By April 15, 2017 and quarterly thereafter
 Review work plan activities of previous quarter at
submit quarterly reports to MDH related to
staff meeting.
activities in this work plan.
 Identify successes and challenges in
implementing activities for the quarter.
 Identify need for technical assistance related to
challenges in achieving activities and objectives.
 Submit quarterly report.
By April 15, 2017 and monthly thereafter
 Implement written informed consent process to
submit data as outlined in the current version
allow reporting of individual-level data to MDH
of the Family Home Visiting Reporting
for MIECHV evaluation purposes.
Guidance document for submission to MDH
 Collect data for performance measurement.
via FHVRES or other designated data reporting  Monitor the quality of data collected for
system.
performance measurement.
 Submit data to FHVRES or other data collection
systems designated by MDH.
By May 1, 2017 develop policies as directed by  Identify all home visiting programs available to
MDH. Policies will include but not be limited to
target population within the community.
a policy assuring coordination of home visiting  Convene a meeting with other home visiting
programs in the community and nonservice providers for the purpose of identifying
duplication of home visiting services.
role and scope of programs to reduce
duplication.
 Develop a written policy that assures ongoing
coordination and collaboration with other service
providers.
By January 1, 2017 for previously funded
 Contact model representative to discuss
MIECHV sites and May 1, 2017 for new
requirements for model affiliation, replication, or
MIECHV sites achieve and maintain model
implementation process.
approval, affiliation or accreditation and retain  Participate in regular, periodic consultation with
model fidelity through the grant period.
model developers/model consultants.
 Review fidelity or quality reports on a quarterly
basis, for opportunities for growth.
By June 1, 2017, a plan with community
 Develop/Implement plans for Help Me Grow
partners will be developed that integrates
referrals.
home visiting into the early childhood system
 Develop/implement plans for how referrals to
in the community and implement the plan
Early Childhood Screening will be made.
throughout the remainder of the grant period.
49
Objectives
By May 1, 2017 for previously funded MIECHV
sites and December 31, 2017 for new MIECHV
sites achieve a full case load of families to be
served and maintain the caseload at 85%
during the grant period.
Activities
 Collaboration and coordination of referral
process within the early childhood system
partners, including Early Head Start to assure a
continuum of services.
 Develop a plan to establish bi-directional
communication between the program and
medical home/behavioral health home.
 Report quarterly to MDH percent of target
caseload being served on Quarterly Progress
Report.
 If below 85% of target, develop plan and provide
progress reports to MDH.
 Supervisor to monitor caseloads on a monthly
basis.
 Conduct CQI activities to improve/maintain client
engagement and retention.
50
Appendix D: Expansion Information Form
The Nurse-Family Partnership Expansion Information Form is available by contacting Amy
Goodhue, Nurse-Family Partnership Nurse Consultant at
[email protected].
If you are a current Nurse-Family Partnership site, you may also access the form by going to the
Nurse-Family Partnership website and logging on to the NFP Community tab.
51
Appendix E: Average MIECHV target caseload served by current grantees during
Calendar Year 2015
The table below gives the quarterly caseload served by each current MIECHV grantee during
Calendar Year 2015, based on data submitted to MDH. Figures include families served by both
MIECHV 1 and MIECHV 2 funds.
Table E1 Average MIECHV Target Caseload Served by Current Grantees During Calenar Year
2015
Grantee
Anoka
Bloomington, City of
Carlton-Cook-Lake-St. Louis
Cass
Dakota
Hennepin
Isanti-Mille Lacs
Kanabec-Pine
Meeker-Mcleod-Sibley
Minneapolis, City of
Morrison-Todd-Wadena
Mower
North Country (Beltrami-Clearwater-HubbardLake of the Woods)
Partnership4Health (Becker-Clay-Otter TailWilkin)
Polk-Norman-Mahnomen
Quin (Marshall-Pennington-Red Lake)
St. Paul-Ramsey
Stearns
Washington
Q1
Q2
Q3
Q4
Average
2015 2015 2015 2015 2015
65
62
69
69
66
24
26
26
35
28
52
49
50
43
49
7
6
6
6
6
52
62
71
70
64
75
80
77
78
78
25
24
24
23
24
73
81
80
81
79
25
22
22
22
23
151
163
188
130
158
10
9
10
11
10
29
26
26
25
27
48
52
53
56
52
51
45
36
40
43
14
30
316
89
45
13
30
317
92
47
12
29
306
73
49
20
28
290
70
48
15
29
307
81
47
52
Appendix F: High Risk Communities Identified in the Statewide Needs
Assessment
County
Aitkin
Anoka
Becker
Beltrami
Big Stone
Carlton
Cass
Clearwater
Cook
Crow Wing
Dakota
Faribault
Hennepin
Hubbard
Itasca
Kanabec
Kandiyohi
Koochiching
Lake
Lake of the Woods
Mahnomen
Marshall
Martin
County
Mille Lacs
Mower
Nobles
Norman
Olmsted
Pennington
Pine
Pipestone
Polk
Pope
Ramsey
Red Lake
Redwood
Scott
Stearns
St. Louis
Swift
Todd
Traverse
Wadena
Washington
Watonwan
Wright
53
Appendix G: Minnesota Department of Health Grant Agreement Sample
Please review the MDH Grant Agreement Sample language on the Family Home Visiting
website. This is sample language only, actual language may vary.
54
Appendix H: Unallowable Uses of MDH Grant Funds
Unallowable costs are expenditures in which grant funds cannot be used. MDH does have
the right to disallow expenditures if grantees do not obtain prior approval. The MDH Grant
Manager will be reviewing invoices and reserves the right to question and/or take action for
inappropriate uses of funds. The following list of unallowable uses of grant funds include,
but are not limited to, the following:
 Alcohol or any illegal substance
 Any cost not directly related to the grant and it’s approved work plan and budget
 Bad debts
 Capital improvements
 Cash assistance paid directly to individuals to meet their personal or family needs
 Contingencies
 Contributions or donations
 Costs incurred prior to or after the grant award (unless otherwise indicated)
 Direct patient medical services or care
 Equipment with an acquisition cost of $5,000 or more per unit
 Fines and penalties
 Gifts for staff
 Goods or services for personal use
 Grant writing
 Interest
 Lobbying at the federal or state level
 Losses on agreements or contracts
 Memberships to clubs, camps, fitness centers and similar groups
 Mischarging of costs
 Personal electronic devices, such as Smart phones, iPhones, iPads, etc.
 Political campaigns on behalf of, or in opposition to, any candidate for public office
 Raffles
 Research
 Scholarships (e.g. camp fees and scholarships for individuals to participate in events)
 Staff meals (except during approved travel)
 Supplanting of funds from other sources
 Transportation (except during approved travel)
 Treatment of a disease or disability
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