Family Home Visiting
Forms Guidance 2015
Family Home Visiting Unit • Maternal & Child Health Section
Community & Family Health Division • Minnesota Department of Health
address: P.O. Box 64882, St. Paul, MN 55164 • phone: 651-201-3760
email: [email protected]
web: www.health.state.mn.us/divs/cfh/program/fhv
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Table of Contents
Contents
Family Home Visiting Forms Guidance 2015 ................................................................................................ 1
Table of Contents .......................................................................................................................................... 2
Completing FHV Evaluation Forms: What to Report ................................................................................ 4
Required Forms ..................................................................................................................................... 4
How to fill out forms ............................................................................................................................. 5
Who to Direct Questions to .................................................................................................................. 5
Caregiver Intake ........................................................................................................................................ 6
Child Intake ............................................................................................................................................. 11
Primary Caregiver Closure ...................................................................................................................... 44
Appendix ................................................................................................................................................. 46
Terms and Acronyms .......................................................................................................................... 46
Reporting for the 2015 FHV Evaluation .................................................................................................. 47
What to Submit ................................................................................................................................... 47
Which Forms to Complete .................................................................................................................. 48
Where to submit ................................................................................................................................. 49
When to Submit .................................................................................................................................. 49
Collection of Name & Address Identifiers........................................................................................... 50
2015 FHV Evaluation: Data to Report to the MDH ................................................................................. 51
List of Validated Screening and Assessment Tools Used in Family Home Visiting (FHV) Evaluation . 52
Maternal Depression Screening Algorithm Edinburgh Postnatal Depression Scale (EPDS) .............. 53
Maternal Depression Screening Algorithm PHQ-9 ............................................................................ 55
Crisis Intervention Algorithm .............................................................................................................. 57
What is Next? Positive Screen for Depression ........................................................................................ 58
What does a positive screen mean? ................................................................................................... 58
FHV MN State Statute ............................................................................................................................. 61
Subdivision 1. Establishment; goals. ................................................................................................... 61
Subd. 2. ............................................................................................................................................... 61
Subd. 3.Requirements for programs; process. ................................................................................... 61
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Subd. 4.Training. ................................................................................................................................. 63
Subd. 4a............................................................................................................................................... 64
Subd. 5. ............................................................................................................................................... 64
Subd. 6. ............................................................................................................................................... 64
Subd. 7. ............................................................................................................................................... 65
Subd. 8. ............................................................................................................................................... 65
Subd. 9. ............................................................................................................................................... 65
TANF Grant Guidelines............................................................................................................................ 66
Eligible Program Services .................................................................................................................... 66
Eligible Populations ............................................................................................................................. 67
Determination and Documentation of Eligibility for Family Home Visiting or WIC Clinic Services .... 67
Matching Requirement ....................................................................................................................... 72
Program and Administrative Costs ..................................................................................................... 73
Reporting Requirements ..................................................................................................................... 73
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Completing FHV Evaluation Forms: What to Report
Per Statute M.S. 145A.17, Family Home Visiting (FHV) data reported to the Minnesota Department of
Health (MDH) is intended to measure the impact of services provided to families. Local public health
home visiting programs provide a variety of services to maternal and child health clients. When
determining what data to collect and report to MDH as part of the FHV evaluation, please refer to the
statute (on page 61) as well as the document, 2015 Family Home Visiting Evaluation: Data to Report to
the Minnesota Department of Health (on page 51), both included in the appendix.
Local public health home visiting programs utilize a variety of funding sources for different types of
home visiting. If TANF funds are used for home visiting, those TANF-funded activities must reflect the
goals of the statute and must be reported to MDH as part of the FHV state evaluation.
The FHV evaluation is comprised of a limited set of variables not intended to capture all best practices in
local FHV programs. Evaluation variables and questions should not serve as a substitute for the broader
range of evidence-based family home visiting best practices implemented in local programs.
For directions on how to report for 2015, please refer to the document, Reporting for the 2015 FHV
Evaluation also in the appendix on page 47.
Required Forms
Regardless of FHV Model, all Caregiver-child dyads require a Caregiver Intake, and eventually a Child
Intake and Closure form. For clients enrolled in NFP, HFA, or long term, ongoing FHV models additional
forms are required depending on whether the appropriate age interval for the dyad is reached. Clients
enrolled in short-term/limited FHV will only need to do the additional forms if the visit(s) fall within the
age interval for a form.
All forms, from Caregiver Intake to Closure, must be filled out for each child. In addition, clients will need
a new Caregiver & Child Intake form for the following situations:
- Caregiver-Child dyad changes FHV model
- Caregiver-Child dyad moves to another local health department’s jurisdiction (i.e. changes Site)
- Caregiver changes for a child
- Caregiver-Child dyad restarts an FHV program for which they have already had a closure form filled
out.
For clients enrolled in NFP, HFA, or “other, ongoing” FHV services, all FHV evaluation forms are
completed for the time frame that the client/child received those services. Data should be collected
within two months before or two months after the specified interval. For example, home visitors can
complete the six month form two months before the child’s sixth month birthday until two months after
the child’s sixth month birthday. Exceptions are the two intake forms. Also, consider the appropriate age
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of the child as required by the screening tools such as the ASQ-3 and the ASQ:SE. If a child’s age is too
young or too old to administer a particular tool during the interval specified in the evaluation form,
please still report data for the rest of the form if the visit is within the two months before or two months
after the specified interval.
For caregivers & children enrolled in NFP, the LPH agencies should complete all forms required by the
NFP model. IN ADDITION, the NFP Supplemental forms should be completed in ETO when the
Caregiver/Child reaches the appropriate interval.
How to fill out forms
For dyads enrolled in HFA, NFP, or Other, Ongoing FHV, MDH expects that all questions in the 2015 FHV
Evaluation be answered if applicable. Short-term/limited dyads may not be required to answer all the
questions of the 2015 FHV Evaluation, but MDH expects the answers to be reported if the home visitor
does collect the data as part of their FHV intervention. For ease of use, required questions for shortterm/limited dyads are marked with an asterisk (*) on the 2015 FHV Evaluation forms.
Answering a question
•
•
•
•
•
Home visitors should fill out every question that they can in the way the form asks.
When the home visitor can’t answer the question or doesn’t know the answer, leave it blank.
o Some questions have “88 Client does not know/not sure” or “99 Client declines to
answer”, which are not the same as a blank.
Don’t create new categories. The Family Home Visiting Reporting and Evaluation System
(FHVRES) will only accept values that are on the forms.
MDH will not evaluate notes in comments sections. FHVRES also does not accept comments.
Sites implementing Nurse-Family Partnership should follow NFP guidance on how to fill out
forms.
Differences among sites
•
•
Different sites have different processes for physically filling out paper and electronic forms.
Refer questions about this process to your local supervisor or to your data system vendor.
If your site does not have a data system, contact [email protected] to get the
correct electronic forms.
Who to Direct Questions to
•
•
•
Nurse Consultants: Questions related to home visiting practice
Data System Vendors: Questions related to how your data system functions
MDH Evaluation Team: Questions related to the evaluation and data submissions
o [email protected]
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Caregiver Intake
Caregiver Intake
When to fill out a caregiver Intake?
•
Client’s first home visit
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
3b Name of subcontracting agency, if
applicable
4 Date of first home visit
Additional guidance
The person doing the data entry into your system. This field
allows sites to filter data reports by staff. MDH won’t use
this information for other purposes.
This field allows sites to filter data reports by staff. MDH
won’t use this information for other purposes.
The health department site (county or city) where the client
lives.
Only fill this out if there is a subcontracting agency
performing family home visiting. If there is a new
subcontracting agency that doesn’t appear on this list,
contact [email protected]
For ongoing home visiting: This field should be the date of
the first home visit after the client has been determined to
be eligible and has been enrolled in home visiting. For
example, do not record the date of the Parent Survey.
For short-term/limited home visiting: This date can be when
the client is assessed.
5
6 First name
7a Last name
7b Maiden name, if applicable
8a Identifier #1
8b Identifier #2
9 Home address (number and street or
rural route)
10 City
11 State
12 Zip
13 Birth date
14 Home visiting model
For more information, see appendix: “2015 FHV Evaluation:
Data to Report to the MDH” on page 51
There is no #5. MDH will fix this in future versions.
Any previous legal last name. Collected for use in deduplication of FHV data
CaregiverID
Optional field that local health departments and data
systems may use as an additional identifier. MDH won’t use
this information for other purposes.
If homeless, write "homeless" in the address field.
To better understand the difference between long term vs
short term home visiting, see appendix: “FHV Evaluation
Data to Report to the MDH” on page 51
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Caregiver Intake
Question in the forms
15 Funding source
16 Client type at enrollment
(relationship to index child)
17 Gender
18 PRENATAL/POSTPARTUM ONLY: How
many live births have you had?
19 Hispanic or Latino/a ethnicity
Additional guidance
This question is intended to differentiate MIECHV vs nonMIECHV funded services.
“Postpartum mother (biological)” is for any biological
mother who is not pregnant.
If the primary caregiver is the biological mother of the index
child (born or unborn), how many live births did she have
before the index child? Do not count the index child.
The responses regarding ethnicity and race should reflect
what the person considers herself/himself to be and are not
based on percentages of ancestry.
Hispanic origin can be viewed as the heritage, nationality
group, lineage, or country of birth of the person or the
person’s parents or ancestors before their arrival in the
United States.
20 Race (select one or more)
People who identify their origin as Hispanic, Latino, or
Spanish may be any race.
The responses regarding ethnicity and race should reflect
what the person considers herself/himself to be and are not
based on percentages of ancestry.
If home visitor selects “other” for this question, they must
specify.
Do not specify “multiracial” or “biracial”. If a client is more
than one race, select each appropriate race.
21 Primary language
White – A person having origins in any of the original
peoples of Europe, the Middle East, or North Africa.
Black or African American – A person having origins in any of
the Black racial groups of Africa.
American Indian or Alaska Native – A person having origins
in any of the original peoples of North and South America
(including Central America) and who maintains tribal
affiliation or community attachment.
Asian – A person having origins in any of the original peoples
of the Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Native Hawaiian or Other Pacific Islander – A person having
origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.
The language that is used in the home most of the time
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Caregiver Intake
Question in the forms
22 Legal marital status
23 PRENATAL CLIENTS ONLY: How many
weeks pregnant are you (client) now?
24 In the past 6 months, have you
(client) obtained care at the emergency
room/urgent care center for ANY
reason?
25 Are you (client) currently working?
26 What is your (client's) household
size?
Additional guidance
Select "01 Married" if the client is legally married in the
United States
Note the categories provided for marital status. Do not
create additional categories such as “single”, “living
together”, etc.
Weeks pregnant at date of first home visit (refer to #4).
Round down to the nearest week.
If the mother was not enrolled prenatally, leave this blank.
FHVRES will reject an answer of “0”.
It might help if the home visitor makes this question more
specific to the current time period. For example, if the visit
happens in March, the home visitor could ask “Since
September, have you obtained care…”
“No, Not employed” indicates that the person is not working
for pay (this category may include, for example, students,
homemakers and those actively seeking work but currently
not employed).
Someone who receives disability and is not currently working
is “No, not employed”. Disability income is counted in
household income question.
A "household" is defined as a group of related or non-related
individuals who are living together as one economic unit
sharing income and consumption of goods and/or services
(who stay there at least 4 nights per week on average and
contribute to the support of the child or primary caregiver).
Tenants/boarders shall not be counted as members of the
household.
A pregnant woman should be counted as two, taking into
consideration the unborn fetus(es).
27 Do any members of your (client's)
household currently serve in the Armed
Forces (active or reserve)?
Household size: total number of individuals sharing income
and consumption of goods and/or services.
A "household" is defined as a group of related or non-related
individuals who are living together as one economic unit
sharing income and consumption of goods and/or services
(who stay there at least 4 nights per week on average and
contribute to the support of the child or primary caregiver).
Tenants/boarders shall not be counted as members of the
household. Household size: total number of individuals
sharing income and consumption of goods and/or services.
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Caregiver Intake
Question in the forms
28 Which category best describes your
(client's) total annual household income
and benefits?
Additional guidance
A "household" is defined as a group of related or non-related
individuals who are living together as one economic unit
sharing income and consumption of goods and/or services
(who stay there at least 4 nights per week on average and
contribute to the support of the child or primary caregiver).
Tenants/boarders shall not be counted as members of the
household. Household size: total number of individuals
sharing income and consumption of goods and/or services.
"Income and benefits" should include annual earnings from
• work
• rent from tenants/borders
• cash assistance from friends/relatives
• child support payments
• TANF
• MFIP/Cash Grant
• Social Security (SSI/SSDI/OAI)
• Unemployment Insurance)
Consider calculating household income in a similar way you
might be determining eligibility for other services like MCH
or TANF.
29 In what educational program are you
(client) currently enrolled, if any?
30 What is the highest level of education
you (client) have attained?
31 In the past 6 months, have you
(client) completed any educational
programs or classes, such as grade
advancement, certificate, ESOL, etc.?
32 Do you (client) have health
insurance?
Annual income data can be estimated from monthly data
(monthly income x 12).
ESOL = English for Speakers of Other Languages, also
sometimes referred to as English as a Second Language (ESL)
or English as a New Language (ENL)
It might help if the home visitor makes this question more
specific to the current time period. For example, if the visit
happens in March, the home visitor could ask “Since
September, have you completed any…”
“02 No, uninsured” Includes clients who have applied for
insurance (pending)
Home visitors who encounter caregivers who do not have
health insurance coverage are encouraged to use
MNsure.org for coverage options available in Minnesota
state.
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Caregiver Intake
Question in the forms
33 What is your major medical care
resource for health insurance? (select
one or more)
Additional guidance
“02 Public insurance” includes any Minnesota Health Care
Programs (MHCP): Medical Assistance (MA), Prepaid Medical
Assistance Program (PMAP), MinnesotaCare, Minnesota
Family Planning Program
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Child Intake
Child Intake
When to fill out child intake?
• Caregivers enrolled prenatally: fill out child intake at first postpartum visit
• Caregivers enrolled after child’s birth: fill out child intake at the first visit – usually the
same visit as the caregiver intake
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
3b Name of subcontracting agency, if applicable
4 Date of home visit
5 Total # home visits to-date
6 First name (child)
7 Last name (child)
8a Identifier #1 (child)
8b Identifier #2 (child)
9 Primary caregiver ID
10 Birth date (child)
11 Gender
Additional guidance
The person doing the data entry into your system.
The health department site (county or city) where
the client lives.
Only fill this out if there is a subcontracting
agency performing family home visiting. If there is
a new subcontracting agency that doesn’t appear
on this list, contact [email protected]
Include the total number of visits with the
caregiver, including the current visit and any
previous FHV visits related to the current child.
ChildID
Optional field that local health departments and
data systems may use as an additional identifier.
MDH won’t use this information for other
purposes.
CaregiverID
Please double check this field for accuracy. It’s
very important for many evaluation measures,
and difficult for FHVRES to catch mistakes.
Child’s gender
11
Child Intake
Question in the forms
12 Hispanic or Latino/a ethnicity
Additional guidance
Child’s ethnicity
The responses regarding ethnicity and race
should reflect what the person considers their
child to be and are not based on percentages of
ancestry.
Hispanic origin can be viewed as the heritage,
nationality group, lineage, or country of birth of
the person or the person’s parents or ancestors
before their arrival in the
United States.
13 Race (child) (select one or more)
People who identify their origin as Hispanic,
Latino, or Spanish may be any race.
The responses regarding ethnicity and race
should reflect what the person considers their
child to be and are not based on percentages of
ancestry.
If home visitor selects “other” for this question,
they must specify.
Do not specify “multiracial” or “biracial”. If a
client is more than one race, select each
appropriate race.
White – A person having origins in any of the
original peoples of Europe, the Middle East, or
North Africa.
Black or African American – A person having
origins in any of the Black racial groups of Africa.
American Indian or Alaska Native – A person
having origins in any of the original peoples of
North and South America (including Central
America) and who maintains tribal affiliation or
community attachment.
Asian – A person having origins in any of the
original peoples of the Far East, Southeast Asia, or
the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Native Hawaiian or Other Pacific Islander – A
person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.
12
Child Intake
Question in the forms
14 BIOLOGICAL MOTHERS ONLY: Did you (client)
smoke cigarettes at all during pregnancy,
including before you found out you were
pregnant?
15 ANSWER ONLY IF ENROLLED PRENATALLY:
Since enrollment, have you (client) obtained care
at the emergency room/urgent care center for
ANY reason?
16 ANSWER ONLY IF ENROLLED PRENATALLY:
Since enrollment, have you (client) completed
any educational programs or classes, such as
grade advancement, certificate, ESOL, etc.?
Additional guidance
This includes electronic cigarettes (e-cigs).
17 ANSWER ONLY IF ENROLLED PRENATALLY: Do
you (client) have health insurance?
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
18 ANSWER ONLY IF ENROLLED PRENATALLY:
What is your major medical care resource for
health insurance? (select one or more)
19 Does your child have health insurance?
20 What is your child's major medical care
resource for health insurance? (select one or
more)
ESOL = English for Speakers of Other Languages,
also sometimes referred to as English as a Second
Language (ESL) or English as a New Language
(ENL)
Home visitors who encounter caregivers who do
not have health insurance coverage are
encouraged to use MNsure.org for coverage
options available in Minnesota state.
Caregiver’s major medical care resource
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical
Assistance (MA), Prepaid Medical Assistance
Program (PMAP), MinnesotaCare, Minnesota
Family Planning Program
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical
Assistance (MA), Prepaid Medical Assistance
Program (PMAP), MinnesotaCare, Minnesota
Family Planning Program
13
6 Months Infant
Fill out 6 months infant form when child is 4 months 0 days to 7 months 30 days
Questions with more specific time requirements
• #10 depression screening: screened by 3 months postpartum, reported on 6 months form
• #25 NCAST: assessed by 3 months postpartum, reported on 6 months form
• #26 - #29 ASQ-3 (4 months questionnaire): follow ASQ guidance for when to complete
• #30 domestic violence screening: screened by 3 months postpartum, reported on 6 months
form
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
3b Name of subcontracting agency, if applicable
4 Date of home visit
5 Total # home visits to-date
6 Child ID
7 Primary caregiver ID
8 Legal marital status
9 BIOLOGICAL MOTHERS ONLY: Are you (client) taking
a vitamin containing folic acid?
Additional guidance
The person doing the data entry into your
system.
The health department site (county or city)
where the client lives.
Only fill this out if there is a subcontracting
agency performing family home visiting. If there
is a new subcontracting agency that doesn’t
appear on this list, contact
[email protected]
Include the total number of visits with the
caregiver, including the current visit and any
previous FHV visits related to the current child.
Select "01 Married" if the client is legally
married in the United States
Note the categories provided. Do not create
additional categories such as “single”, “living
together”, etc.
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6 Months Infant
Question in the forms
10 BIOLOGICAL MOTHERS ONLY: Was the mother
screened with a standardized instrument (EPDS, PHQ2, or PHQ-9) for possible postpartum depression by 3
months postpartum?
Additional guidance
The best practice is for the home visitors to
perform this screen themselves. This tool
should only be used by home visitors who have
been oriented or trained on it. If a home visitor
is not familiar with the tool or how to use it,
consult with your supervisor
This must be done with fidelity to the model
(i.e., for NFP, a nurse completes the screening.
However, the question does not specify if it’s
the home visitor or other health care
professional doing the screening.
11 BIOLOGICAL MOTHERS ONLY: Was the mother
referred to relevant community resources for
screening positive for postpartum depression? (Use
EPDS or PHQ-9)
12 Has your child ever had breast milk?
13 Does your child continue to get breast milk?
14 How many weeks old was your child when he or
she stopped getting breast milk?
15 In the past 6 months, have you (client) obtained
care at the emergency room/urgent care center for
ANY reason?
16 In the past 6 months, have you (client) taken your
child to the emergency room/urgent care center for
an injury?
The PHQ-2 is a pre-screen and if it is positive a
PHQ-9 should be used.
Use the tool’s guidance and clinical judgment to
decide whether or not the caregiver needs a
referral.
Refer to appendix: Maternal Depression
Screening Algorithms on page 53
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with
caregiver’s permission
Enter "1" if less than one week. Only enter
integers and round up to the nearest week.
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you obtained care…”
Specifically for injury
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you taken your child…”
15
6 Months Infant
Question in the forms
17 In the past 6 months, have you (client) taken your
child to the emergency room/urgent care center for
ANY reason, including injury?
18 Does this client have a home safety checklist (or
equivalent) completed?
19 Is there currently an active file at the lead Child
Protection Agency (CPA) of suspected maltreatment
for this child?
20 Was the suspected case of maltreatment
substantiated by the lead CPA?
21 Was the child of the substantiated case of
maltreatment a first-time victim, as reported by lead
CPA?
22 What is the child's current weight?
23 What is the child's current length? (head-to-toe)
24 Does your agency (home visiting) have an NCAST
trained staff person?
25 NCAST Teaching Subscale Scores by 3 months
postpartum (initial assessment):
26 Has the home visitor discussed the child's ASQ-3
scores at 4 months of age with the primary caregiver?
27 Please indicate whether the child's ASQ-3 scores at
4 months of age were below the established referral
score cutoff in the following areas? Note: Checked
box = scored below the cutoff (i.e., did not meet
developmental milestone)
Additional guidance
For any reason
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you obtained care…”
The Home Safety Checklist (Minnesota
Department of Health) is available online in
English or Spanish at
http://www.health.state.mn.us/divs/cfh/
program/fhv/homevisitor.cfm#tools
This will likely require local public health to
contact other local agencies to access this
information.
Not necessarily the specific home visitor
assigned to the family. The NCAST can be
performed by any person trained to use the
NCAST.
MDH provides training to use the NCAST.
Only fill this out if someone trained to use the
NCAST administers the assessment for the
caregiver. Otherwise leave it blank.
16
6 Months Infant
Question in the forms
28 (If home visitor checked any box for question 27)
Was the child referred to relevant community
resources for scoring below any referral score cutoff
for Communication, Gross Motor, Fine Motor,
Problem Solving, or Personal-Social areas on the ASQ3?
29 Was an appointment made for further
screening/assessment of the child referred to
relevant community resources?
30 BIOLOGICAL MOTHERS ONLY: Was the client
screened for the presence of domestic violence using
the NFP Relationship Assessment or HFA Humiliation
Afraid Rape Kick Child Survey (HARK-C) by 3 months
postpartum?
31 Did the screening tool reveal evidence of domestic
violence?
32 Was a referral made to relevant domestic violence
services and noted in the client's chart?
33 Was an intimate partner violence safety plan
discussed, completed, or reviewed?
34 Are you (client) currently working?
Additional guidance
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with
caregiver’s permission
• Ongoing services provided by the
agency
Services might include: health providers, Help
Me Grow, private therapy services, Follow
Along Program, Early Childhood Special
Education (ECSE)
We want to know if an appointment was made,
either by the home visitor or by the caregiver.
HARK-C: A cutoff score of 1 will be used as
criteria for a positive screen. Source: Sohal , et.
al. BMC Family Practice 2007 8:49.
Examples of referrals include:
• Confidentially provide information
about services
• Assist caregiver in accessing services
Follow the guidance of your own agency, or
access intimate partner violence resources in
your county/region.
“No, Not employed” indicates that the person is
not working for pay (this category may include,
for example, students, homemakers and those
actively seeking work but currently not
employed).
Someone who receives disability and is not
currently working is “No, not employed”.
Disability income is counted in household
income question.
17
6 Months Infant
Question in the forms
35 What is your (client's) household size? (Note:
Count 1 for yourself)
Additional guidance
A "household" is defined as a group of related
or non-related individuals who are living
together as one economic unit sharing income
and consumption of goods and/or services
(who stay there at least 4 nights per week on
average and contribute to the support of the
child or primary caregiver). Tenants/boarders
shall not be counted as members of the
household.
A pregnant woman should be counted as two,
taking into consideration the unborn fetus(es).
36 Which category best describes your (client's) total
annual household income and benefits?
Household size: total number of individuals
sharing income and consumption of goods
and/or services.
A "household" is defined as a group of related
or non-related individuals who are living
together as one economic unit sharing income
and consumption of goods and/or services
(who stay there at least 4 nights per week on
average and contribute to the support of the
child or primary caregiver). Tenants/boarders
shall not be counted as members of the
household. Household size: total number of
individuals sharing income and consumption of
goods and/or services.
"Income and benefits" should include annual
earnings from
•
•
•
•
•
•
•
work
rent from tenants/borders
cash assistance from friends/relatives
child support payments
TANF
Social Security (SSI/SSDI/OAI)
Unemployment Insurance)
Consider calculating household income in a
similar way you might be determining eligibility
for other services like MCH or TANF.
Annual income data can be estimated from
monthly data (monthly income x 12).
18
6 Months Infant
Question in the forms
37 In what educational program are you (client)
currently enrolled, if any?
38 What is the highest level of education you (client)
have attained?
39 In the past 6 months, have you (client) completed
any educational programs or classes, such as grade
advancement, certificate, ESOL, etc.?
40 Do you (client) have health insurance?
41 What is your major medical care resource for
health insurance? (select one or more)
42 Does your child have health insurance?
43 What is your child's major medical care resource
for health insurance? (select one or more)
Additional guidance
ESOL = English for Speakers of Other Languages,
also sometimes referred to as English as a
Second Language (ESL) or English as a New
Language (ENL)
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you completed…”
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
Home visitors who encounter caregivers who
do not have health insurance coverage are
encouraged to use MNsure.org for coverage
options available in Minnesota state.
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical
Assistance (MA), Prepaid Medical Assistance
Program (PMAP), MinnesotaCare, Minnesota
Family Planning Program
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical
Assistance (MA), Prepaid Medical Assistance
Program (PMAP), MinnesotaCare, Minnesota
Family Planning Program
19
12 Months Infant
Fill out 12 months infant form when child is 10 months 0 days to 13 months 30 days
Questions with more specific time requirements
• #25 – #28 ASQ-3 (10/12 months questionnaire) follow ASQ guidance for when to complete
• #29 – #32 ASQ:SE (12 months questionnaire) follow ASQ guidance for when to complete
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
3b Name of subcontracting agency, if applicable
4 Date of home visit
5 Total # home visits to-date
6 Child ID
7 Primary caregiver ID
8 Legal marital status1
9 BIOLOGICAL MOTHERS ONLY: Are you (client) taking
a vitamin containing folic acid?
10 BIOLOGICAL MOTHERS ONLY: Since you had your
child, have you (client) been pregnant again?
11 Has your child ever had breast milk?
12 Does your child continue to get breast milk?
13 How many weeks old was your child when he or
she stopped getting breast milk?
14 Has your child had 50% of their well-child checkups?
Additional guidance
The person doing the data entry into your
system.
The health department site (county or city)
where the client lives.
Only fill this out if there is a subcontracting
agency performing family home visiting. If there
is a new subcontracting agency that doesn’t
appear on this list, contact
[email protected]
Include the total number of visits with the
caregiver, including the current visit and any
previous FHV visits related to the current child.
Select "01 Married" if the client is legally
married in the United States.
Enter "1" if less than one week. Only enter
integers and round up to the nearest week.
Determine number of well-child visits by use of
recognized schedule, such as: Follow-along
Program, AAP Recommendations for Preventive
Pediatric Health Care, or the Minnesota Child
and Teen Checkups (C&TC) Early and Periodic
Screening, Diagnosis & Treatment Schedule of
Age-Related Screening Standards.
Do NOT count a well-child check-up that has
been scheduled but not yet completed.
20
12 Months Infant
Question in the forms
15 In the past 6 months, have you (client) obtained
care at the emergency room/urgent care center for
ANY reason?
16 In the past 6 months, have you (client) taken your
child to the emergency room/urgent care center for
an injury?
17 In the past 6 months, have you (client) taken your
child to the emergency room/urgent care center for
ANY reason, including injury?
18 Is there currently an active file at the lead Child
Protection Agency (CPA) of suspected maltreatment
for this child?
19 Was the suspected case of maltreatment
substantiated by the lead CPA?
20 Was the child of the substantiated case of
maltreatment a first-time victim, as reported by lead
CPA?
21 What is the child's current weight?
22 What is the child's current length? (head-to-toe)
23 Does your agency (home visiting) have an NCAST
trained staff person?
24 NCAST Teaching Subscale Scores at 12 months of
child age
25 Has the home visitor discussed the child's ASQ-3
scores at 10/12 months of age with the primary
caregiver?
26 Please indicate whether the child's ASQ-3 scores at
10/12 months of age were below the established
referral score cutoff in the following areas? Note:
Checked box = scored below the cutoff (i.e., did not
meet developmental milestone)
Additional guidance
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you obtained care…”
Specifically for injury
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you taken your child…”
For any reason
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you taken your child…”
This will likely require local public health to
contact other local agencies to access this
information.
Not necessarily the specific home visitor
assigned to the family. The NCAST can be
performed by any person trained to use the
NCAST.
MDH provides training to use the NCAST.
This question is only for ASQ-3 scores at 10/12
months of age, NOT at any other age. For
example, do not use this question in reference
to an 8 month screen.
This question is only for ASQ-3 scores at 10/12
months of age, NOT at any other age. For
example, do not use this question in reference
to an 8 month screen.
21
12 Months Infant
Question in the forms
27 If home visitor checked any box for question 26:
Was the child referred to relevant community
resources for scoring below any referral score cutoff
for Communication, Gross Motor, Fine Motor,
Problem Solving, or Personal-Social areas on the ASQ3?
28 Was an appointment made for further
screening/assessment of the child referred to
relevant community resources?
29 Has the home visitor discussed the child's ASQ:SE
scores at 12 months of age with the primary
caregiver?
30 Please indicate whether the child's ASQ:SE score at
12 months of age was above the established referral
score cutoff. Note: Checked box = scored above the
cutoff (i.e., did not meet socio-emotional milestones)
31 (If home visitor checked the box for question 30)
Was the child referred to relevant community
resources for scoring above the referral score cutoff
on the ASQ:SE?
32 Was an appointment made for further
screening/assessment of the child referred to
relevant community resources?
33 BIOLOGICAL MOTHERS ONLY: Was the client
screened for the presence of domestic violence using
the NFP Relationship Assessment or HFA Humiliation
Afraid Rape Kick Child Survey (HARK-C)?
34 Did the screening tool reveal evidence of domestic
violence?
Additional guidance
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with
caregiver’s permission
• Ongoing services provided by the
agency
Services might include: health providers, Help
Me Grow, private therapy services, Follow
Along Program, Early Childhood Special
Education (ECSE)
We want to know if an appointment was made,
either by the home visitor or by the caregiver.
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with
caregiver’s permission
• Ongoing services provided by the
agency
Services might include: health providers, Help
Me Grow, private therapy services, Follow
Along Program, Early Childhood Special
Education (ECSE), infant mental health
providers
We want to know if an appointment was made,
either by the home visitor or by the caregiver.
This question should read: “In the past 6
months”. This change will be made in next
year’s forms.
HARK-C: A cutoff score of 1 will be used as
criteria for a positive screen. Source: Sohal , et.
al. BMC Family Practice 2007 8:49.
22
12 Months Infant
Question in the forms
35 Was a referral made to relevant domestic violence
services and noted in the client's chart?
36 Was an intimate partner violence safety plan
discussed, completed, or reviewed?
37 Are you (client) currently working?
38 What is your (client's) household size? (Note:
Count 1 for yourself)
Additional guidance
Examples of referrals include:
• Confidentially provide information
about services
• Assist caregiver in accessing services
Follow the guidance of your own agency, or
access intimate partner violence resources in
your county/region.
“No, Not employed” indicates that the person is
not working for pay (this category may include,
for example, students, homemakers and those
actively seeking work but currently not
employed).
Someone who receives disability and is not
currently working is “No, not employed”.
Disability income is counted in household
income question.
A "household" is defined as a group of related
or non-related individuals who are living
together as one economic unit sharing income
and consumption of goods and/or services
(who stay there at least 4 nights per week on
average and contribute to the support of the
child or primary caregiver). Tenants/boarders
shall not be counted as members of the
household.
A pregnant woman should be counted as two,
taking into consideration the unborn fetus(es).
Household size: total number of individuals
sharing income and consumption of goods
and/or services.
23
12 Months Infant
Question in the forms
39 Which category best describes your (client's) total
annual household income and benefits?
Additional guidance
A "household" is defined as a group of related
or non-related individuals who are living
together as one economic unit sharing income
and consumption of goods and/or services
(who stay there at least 4 nights per week on
average and contribute to the support of the
child or primary caregiver). Tenants/boarders
shall not be counted as members of the
household. Household size: total number of
individuals sharing income and consumption of
goods and/or services.
"Income and benefits" should include annual
earnings from
•
•
•
•
•
•
•
work
rent from tenants/borders
cash assistance from friends/relatives
child support payments
TANF
Social Security (SSI/SSDI/OAI)
Unemployment Insurance)
Consider calculating household income in a
similar way you might be determining eligibility
for other services like MCH or TANF.
40 In what educational program are you (client)
currently enrolled, if any?
41 What is the highest level of education you (client)
have attained?
42 In the past 6 months, have you (client) completed
any educational programs or classes, such as grade
advancement, certificate, ESOL, etc.?
Annual income data can be estimated from
monthly data (monthly income x 12).
ESOL = English for Speakers of Other Languages,
also sometimes referred to as English as a
Second Language (ESL) or English as a New
Language (ENL)
It might help if the home visitor makes this
question more specific to the current time
period. For example, if the visit happens in
March, the home visitor could ask “Since
September, have you completed…”
24
12 Months Infant
Question in the forms
43 Do you (client) have health insurance?
44 What is your major medical care resource for
health insurance? (select one or more)
45 Does your child have health insurance?
46 What is your child's major medical care resource
for health insurance? (select one or more)
Additional guidance
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
Home visitors who encounter caregivers who
do not have health insurance coverage are
encouraged to use MNsure.org for coverage
options available in Minnesota state.
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical
Assistance (MA), Prepaid Medical Assistance
Program (PMAP), MinnesotaCare, Minnesota
Family Planning Program
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical
Assistance (MA), Prepaid Medical Assistance
Program (PMAP), MinnesotaCare, Minnesota
Family Planning Program
25
18 Months Toddler
Fill out 18 months infant form when child is 16 months 0 days to 19 months 30 days
Questions with more specific time requirements
• #20 – #23 ASQ-3 (18 months questionnaire): follow ASQ guidance for when to complete
• #24 – #27 ASQ:SE (18 months questionnaire): follow ASQ guidance for when to complete
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
3b Name of subcontracting agency, if applicable
4 Date of home visit
5 Total # home visits to-date
6 Child ID
7 Primary caregiver ID
8 BIOLOGICAL MOTHERS ONLY: Are you (client)
taking a vitamin containing folic acid?
9 BIOLOGICAL MOTHERS ONLY: Since you had your
child, have you (client) been pregnant again?
10 Has your child ever had breast milk?
11 Does your child continue to get breast milk?
12 How many weeks old was your child when he or
she stopped getting breast milk?
13 In the past 6 months, have you (client)
obtained care at the emergency room/urgent care
center for ANY reason?
14 In the past 6 months, have you (client) taken
your child to the emergency room/urgent care
center for an injury?
Additional guidance
The person doing the data entry into your system.
The health department site (county or city) where
the client lives.
Only fill this out if there is a subcontracting agency
performing family home visiting. If there is a new
subcontracting agency that doesn’t appear on this
list, contact [email protected]
Include the total number of visits with the
caregiver, including the current visit and any
previous FHV visits related to the current child.
Enter "1" if less than one week. Only enter
integers and round up to the nearest week.
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
obtained care…”
Specifically for injury
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
taken your child…”
26
18 Months Toddler
Question in the forms
15 In the past 6 months, have you (client) taken
your child to the emergency room/urgent care
center for ANY reason, including injury?
16 What is the child's current weight?
Additional guidance
For any reason
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
taken your child…”
17 What is the child's current length? (head-totoe)
18 Does your agency (home visiting) have an
NCAST trained staff person?
19 NCAST Teaching Subscale Scores at 18 months
of age:
20 Has the home visitor discussed the child's ASQ3 scores at 18 months of age with the primary
caregiver?
21 Please indicate whether the child's ASQ-3
scores at 18 months of age were below the
established referral score cutoff in the following
areas? Note: Checked box = scored below the
cutoff (i.e., did not meet developmental
milestone)
22 (If home visitor checked any box for question
21) Was the child referred to relevant community
resources for scoring below any referral score
cutoff for Communication, Gross Motor, Fine
Motor, Problem Solving, or Personal-Social areas
on the ASQ-3?
23 Was an appointment made for further
screening/assessment of the child referred to
relevant community resources?
24 Has the home visitor discussed the child's
ASQ:SE scores at 18 months of age with the
primary caregiver?
Not necessarily the specific home visitor assigned
to the family. The NCAST can be performed by any
person trained to use the NCAST.
MDH provides training to use the NCAST.
Use 18 months questionnaire
Use 18 months questionnaire
Use 18 months questionnaire
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with caregiver’s
permission
• Ongoing services provided by the agency
Services might include: health providers, Help Me
Grow, private therapy services, Follow Along
Program, Early Childhood Special Education (ECSE)
We want to know if an appointment was made,
either by the home visitor or by the caregiver.
Use 18 months questionnaire
27
18 Months Toddler
Question in the forms
25 Please indicate whether the child's ASQ:SE
score at 18 months of age was above the
established referral score cutoff. Note: Checked
box = scored above the cutoff (i.e., did not meet
socio-emotional milestones)
26 (If home visitor checked the box for question
29) Was the child referred to relevant community
resources for scoring above the referral score
cutoff on the ASQ:SE?
27 Was an appointment made for further
screening/assessment of the child referred to
relevant community resources?
28 BIOLOGICAL MOTHERS ONLY: Was the client
screened for the presence of domestic violence
using the NFP Relationship Assessment or HFA
Humiliation Afraid Rape Kick Child Survey (HARKC)?
29 Did the screening tool reveal evidence of
domestic violence?
30 Was a referral made to relevant domestic
violence services and noted in the client's chart?
31 Was an intimate partner violence safety plan
discussed, completed, or reviewed?
Additional guidance
Use 18 months questionnaire
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with caregiver’s
permission
• Ongoing services provided by the agency
Services might include: health providers, Help Me
Grow, private therapy services, Follow Along
Program, Early Childhood Special Education (ECSE),
infant mental health providers
We want to know if an appointment was made,
either by the home visitor or by the caregiver.
HARK-C: A cutoff score of 1 will be used as criteria
for a positive screen. Source: Sohal , et. al. BMC
Family Practice 2007 8:49.
Examples of referrals include:
• Confidentially provide information about
services
• Assist caregiver in accessing services
Follow the guidance of your own agency, or access
intimate partner violence resources in your
county/region.
28
18 Months Toddler
Question in the forms
32 Which category best describes your (client's)
total annual household income and benefits?
Additional guidance
A "household" is defined as a group of related or
non-related individuals who are living together as
one economic unit sharing income and
consumption of goods and/or services (who stay
there at least 4 nights per week on average and
contribute to the support of the child or primary
caregiver). Tenants/boarders shall not be counted
as members of the household. Household size:
total number of individuals sharing income and
consumption of goods and/or services.
"Income and benefits" should include annual
earnings from
•
•
•
•
•
•
•
work
rent from tenants/borders
cash assistance from friends/relatives
child support payments
TANF
Social Security (SSI/SSDI/OAI)
Unemployment Insurance)
Consider calculating household income in a similar
way you might be determining eligibility for other
services like MCH or TANF.
33 In the past 6 months, have you (client)
completed any educational programs or classes,
such as grade advancement, certificate, ESOL,
etc.?
34 Do you (client) have health insurance?
Annual income data can be estimated from
monthly data (monthly income x 12).
ESOL = English for Speakers of Other Languages,
also sometimes referred to as English as a Second
Language (ESL) or English as a New Language (ENL)
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
completed…”
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
Home visitors who encounter caregivers who do
not have health insurance coverage are
encouraged to use MNsure.org for coverage
options available in Minnesota state.
29
18 Months Toddler
Question in the forms
35 What is your major medical care resource for
health insurance? (select one or more)
36 Does your child have health insurance?
37 What is your child's major medical care
resource for health insurance? (select one or
more)
Additional guidance
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical Assistance
(MA), Prepaid Medical Assistance Program
(PMAP), MinnesotaCare, Minnesota Family
Planning Program
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical Assistance
(MA), Prepaid Medical Assistance Program
(PMAP), MinnesotaCare, Minnesota Family
Planning Program
30
24 months toddler
Fill out 24 months infant form when child is 22 months 0 days to 25 months 31 days
Questions with more specific time requirements
• #21 – #24 ASQ-3 (24 months questionnaire): follow ASQ guidance for when to complete
• #25 – #28 ASQ:SE (24 months questionnaire): follow ASQ guidance for when to complete
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
3b Name of subcontracting agency, if applicable
4 Date of home visit
5 Total # home visits to-date
6 Child ID
7 Primary caregiver ID
8 BIOLOGICAL MOTHERS ONLY: Are you (client)
taking a vitamin containing folic acid?
9 BIOLOGICAL MOTHERS ONLY: Since you had your
child, have you (client) been pregnant again?
10 Has your child ever had breast milk?
11 Does your child continue to get breast milk?
12 How many weeks old was your child when he or
she stopped getting breast milk?
13 Has your child had 50% of their well-child
check-ups?
14 In the past 6 months have you (client) obtained
care at the emergency room/urgent care center
for ANY reason?
Additional guidance
The person doing the data entry into your system.
The health department site (county or city) where
the client lives.
Only fill this out if there is a subcontracting agency
performing family home visiting. If there is a new
subcontracting agency that doesn’t appear on this
list, contact [email protected]
Include the total number of visits with the
caregiver, including the current visit and any
previous FHV visits related to the current child.
Enter "1" if less than one week. Only enter
integers and round up to the nearest week.
Determine number of well-child visits by use of
recognized schedule, such as: Follow-along
Program, AAP Recommendations for Preventive
Pediatric Health Care, or the Minnesota Child and
Teen Checkups (C&TC) Early and Periodic
Screening, Diagnosis & Treatment Schedule of
Age-Related Screening Standards. Do NOT count a
well-child check-up that has been scheduled but
not yet completed. Example: 5 of 9 well-child visits
must be completed by 24 months of age to meet
50% of guidelines according to the C&TC schedule.
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
obtained care…”
31
24 months toddler
Question in the forms
15 In the past 6 months, have you (client) taken
your child to the emergency room/urgent care
center for an injury?
16 In the past 6 months, have you (client) taken
your child to the emergency room/urgent care
center for ANY reason, including injury?
17 What is the child's current weight?
18 What is the child's current length? (head-totoe)
19 Does your agency (home visiting) have an
NCAST trained staff person?
20 NCAST Teaching Subscale Scores at 24 months
of age:
21 Has the home visitor discussed the child's ASQ3 scores at 24 months of age with the primary
caregiver?
22 Please indicate whether the child's ASQ-3
scores at 24 months of age were below the
established referral score cutoff in the following
areas? Note: Checked box = scored below the
cutoff (i.e., did not meet developmental
milestone)
23 (If home visitor checked any box for question
22) Was the child referred to relevant community
resources for scoring below any referral score
cutoff for Communication, Gross Motor, Fine
Motor, Problem Solving, or Personal-Social areas
on the ASQ-3?
24 Was an appointment made for further
screening/assessment of the child referred to
relevant community resources?
Additional guidance
Specifically for injury
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
taken your child…”
For any reason
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
taken your child…”
Not necessarily the specific home visitor assigned
to the family. The NCAST can be performed by any
person trained to use the NCAST.
MDH provides training to use the NCAST.
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with caregiver’s
permission
• Ongoing services provided by the agency
Services might include: health providers, Help Me
Grow, private therapy services, Follow Along
Program, Early Childhood Special Education (ECSE)
We want to know if an appointment was made,
either by the home visitor or by the caregiver.
32
24 months toddler
Question in the forms
25 Has the home visitor discussed the child's
ASQ:SE scores at 24 months of age with the
primary caregiver?
26 Please indicate whether the child's ASQ:SE
score at 24 months of age was above the
established referral score cutoff. Note: Checked
box = scored above the cutoff (i.e., did not meet
socio-emotional milestones)
27 (If home visitor checked the box for question
26) Was the child referred to relevant community
resources for scoring above the referral score
cutoff on the ASQ:SE?
28 Was an appointment made for further
screening/assessment of the child referred to
relevant community resources?
29 BIOLOGICAL MOTHERS ONLY: Was the client
screened for the presence of domestic violence
using the NFP Relationship Assessment or HFA
Humiliation Afraid Rape Kick Child Survey (HARKC)?
30 Did the screening tool reveal evidence of
domestic violence?
31 Was a referral made to relevant domestic
violence services and noted in the client's chart?
32 Was an intimate partner violence safety plan
discussed, completed, or reviewed?
Additional guidance
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with caregiver’s
permission
• Ongoing services provided by the agency
Services might include: health providers, Help Me
Grow, private therapy services, Follow Along
Program, Early Childhood Special Education (ECSE),
infant mental health providers
We want to know if an appointment was made,
either by the home visitor or by the caregiver.
HARK-C: A cutoff score of 1 will be used as criteria
for a positive screen. Source: Sohal , et. al. BMC
Family Practice 2007 8:49.
Examples of referrals include:
• Confidentially provide information about
services
• Assist caregiver in accessing services
Follow the guidance of your own agency, or access
intimate partner violence resources in your
county/region.
33
24 months toddler
Question in the forms
33 Which category best describes your (client's)
total annual household income and benefits?
Additional guidance
A "household" is defined as a group of related or
non-related individuals who are living together as
one economic unit sharing income and
consumption of goods and/or services (who stay
there at least 4 nights per week on average and
contribute to the support of the child or primary
caregiver). Tenants/boarders shall not be counted
as members of the household. Household size:
total number of individuals sharing income and
consumption of goods and/or services.
"Income and benefits" should include annual
earnings from
•
•
•
•
•
•
•
work
rent from tenants/borders
cash assistance from friends/relatives
child support payments
TANF
Social Security (SSI/SSDI/OAI)
Unemployment Insurance)
Consider calculating household income in a similar
way you might be determining eligibility for other
services like MCH or TANF.
34 In the past 6 months, have you (client)
completed any educational programs or classes,
such as grade advancement, certificate, ESOL,
etc.?
Annual income data can be estimated from
monthly data (monthly income x 12).
ESOL = English for Speakers of Other Languages,
also sometimes referred to as English as a Second
Language (ESL) or English as a New Language (ENL)
It might help if the home visitor makes this
question more specific to the current time period.
For example, if the visit happens in March, the
home visitor could ask “Since September, have you
completed any…”
34
24 months toddler
Question in the forms
35 Do you (client) have health insurance?
Additional guidance
If “No, uninsured”, skip to # 37.
(The forms say to skip to #38, which is a mistake
that will be corrected in 2016)
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
36 What is your major medical care resource for
health insurance? (select one or more)
37 Does your child have health insurance?
38 What is your child's major medical care
resource for health insurance? (select one or
more)
Home visitors who encounter caregivers who do
not have health insurance coverage are
encouraged to use MNsure.org for coverage
options available in Minnesota state.
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical Assistance
(MA), Prepaid Medical Assistance Program
(PMAP), MinnesotaCare, Minnesota Family
Planning Program
“02 No, uninsured” Includes clients who have
applied for insurance (pending)
“02 Public insurance” includes any Minnesota
Health Care Programs (MHCP): Medical Assistance
(MA), Prepaid Medical Assistance Program
(PMAP), MinnesotaCare, Minnesota Family
Planning Program
35
30 months toddler – 66 months preschooler
•
•
The forms for 30, 36, 42, 48, 54, 60 and 66 months are very similar, so all the guidance is in this
one table with an additional column to indicate which intervals the question is found on.
The numbering is based on the 36 month form.
When to fill out forms
•
•
•
•
•
•
•
•
30 months toddler: 28 months 0 days – 31 months 30 days
36 months preschooler: 34 months 0 days – 37 months 30 days
42 months preschooler: 40 months 0 days – 43 months 30 days
48 months preschooler: 46 months 0 days – 49 months 30 days
54 months preschooler: 52 months 0 days – 55 months 30 days
60 months preschooler: 58 months 0 days – 61 months 30 days
66 months preschooler: 64 months 0 days – 67 months 30 days
Exceptions: ASQ-3, ASQ:SE
Interval
All
All
All
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
All
3b Name of
subcontracting agency, if
applicable
All
All
4 Date of home visit
5 Total # home visits todate
All
All
All
6 Child ID
7 Primary caregiver ID
8 BIOLOGICAL MOTHERS
ONLY: Are you (client)
taking a vitamin
containing folic acid?
Additional guidance
The person doing the data entry into your system.
The health department site (county or city) where the
client lives.
Only fill this out if there is a subcontracting agency
performing family home visiting. If there is a new
subcontracting agency that doesn’t appear on this list,
contact [email protected]
Include the total number of visits with the caregiver,
including the current visit and any previous FHV visits
related to the current child.
36
30 months toddler – 66 months preschooler
Interval Question in the forms
All
9 BIOLOGICAL MOTHERS
ONLY: In the past 6
months, was the mother
screened with a
standardized instrument
(PHQ-2 or PHQ-9) for
depressive symptoms?
Additional guidance
EPDS is not an accepted tool for this time interval.
The best practice is for the home visitors to perform
this screen themselves. This tool should only be used
by home visitors who have been oriented or trained on
it. If a home visitor is not familiar with the tool or how
to use it, consult with your supervisor
This must be done with fidelity to the model (i.e., for
NFP, a nurse completes the screening.
However, the question does not specify if it’s the home
visitor or other health care professional doing the
screening.
All
30, 36
30, 36
30, 36
10 BIOLOGICAL MOTHERS
ONLY: Was the mother
referred to relevant
community resources for
screening positive for
depressive symptoms?
(PHQ-9)
The PHQ-2 is a pre-screen and if it is positive a PHQ-9
should be used.
Use the tool’s guidance and clinical judgment to decide
whether or not the caregiver needs a referral.
Refer to appendix: Maternal Depression Screening
Algorithm PHQ-9 on page 55
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with caregiver’s
permission
11 Has your child ever
had breast milk?
12 Does your child
continue to get breast
milk?
13 How many weeks old
Enter "1" if less than one week. Only enter integers
was your child when he or and round up to the nearest week.
she stopped getting
breast milk?
37
30 months toddler – 66 months preschooler
Interval Question in the forms
36, 48, 14 Has your child had
60
50% of their well-child
check-ups?
All
All
All
All
All
All
15 In the past 6 months,
have you (client) obtained
care at the emergency
room/urgent care center
for ANY reason?
16 In the past 6 months,
have you (client) taken
your child to the
emergency room/urgent
care center for an injury?
17 In the past 6 months,
have you (client) taken
your child to the
emergency room/urgent
care center for ANY
reason, including injury?
18 Does this client have a
home safety checklist (or
equivalent) completed?
19 Is there currently an
active file at the lead
Child Protection Agency
(CPA) of suspected
maltreatment for this
child?
20 Was the suspected
case of maltreatment
substantiated by the lead
CPA?
Additional guidance
Determine number of well-child visits by use of
recognized schedule, such as: Follow-along Program,
AAP Recommendations for Preventive Pediatric Health
Care, or the Minnesota Child and Teen Checkups
(C&TC) Early and Periodic Screening, Diagnosis &
Treatment Schedule of Age-Related Screening
Standards.
Do NOT count a well-child check-up that has been
scheduled but not yet completed. Example: 5 of 9 wellchild visits must be completed by 24 months of age to
meet 50% of guidelines according to the C&TC
schedule.
It might help if the home visitor makes this question
more specific to the current time period. For example,
if the visit happens in March, the home visitor could
ask “Since September, have you obtained care…”
Specifically for injury
It might help if the home visitor makes this question
more specific to the current time period. For example,
if the visit happens in March, the home visitor could
ask “Since September, have you taken your child…”
For any reason
It might help if the home visitor makes this question
more specific to the current time period. For example,
if the visit happens in March, the home visitor could
ask “Since September, have you taken your child…”
The Home Safety Checklist (Minnesota Department of
Health) is available online in English or Spanish at
http://www.health.state.mn.us/divs/cfh/
program/fhv/homevisitor.cfm#tools
This will likely require local public health to contact
other local agencies to access this information.
38
30 months toddler – 66 months preschooler
Interval Question in the forms
All
21 Was the child of the
substantiated case of
maltreatment a first-time
victim, as reported by
lead CPA?
All
22 What is the child's
current weight?
All
23 What is the child's
current height?
30, 36
24 Does your agency
(home visiting) have an
NCAST trained staff
person?
30, 36
All
All
All
25 NCAST Teaching
Subscale Scores (at this
interval):
26 Has the home visitor
discussed the child's ASQ3 scores at [30, 36, 42, 48,
54, 60, 66] months of age
with the primary
caregiver?
27 Please indicate
whether the child's ASQ-3
scores at [30, 36, 42, 48,
54, 60, 66] months of age
were below the
established referral score
cutoff in the following
areas? Note: Checked box
= scored below the cutoff
(i.e., did not meet
developmental milestone)
28 (If home visitor
checked any box for
question 27) Was the
child referred to relevant
community resources for
scoring below any referral
score cutoff for
Communication, Gross
Motor, Fine Motor,
Problem Solving, or
Personal-Social areas on
the ASQ-3?
Additional guidance
This is the first form that asks for weight in pounds
(earlier forms ask for pounds and ounces)
This is the first form that asks for height in feet and
inches (earlier forms ask for length in inches only)
Not necessarily the specific home visitor assigned to
the family. The NCAST can be performed by any person
trained to use the NCAST.
MDH provides training to use the NCAST.
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with caregiver’s
permission
• Ongoing services provided by the agency
Services might include: health providers, Help Me
Grow, private therapy services, Follow Along Program,
Early Childhood Special Education (ECSE)
39
30 months toddler – 66 months preschooler
Interval Question in the forms
All
29 Was an appointment
made for further
screening/assessment of
the child referred to
relevant community
resources?
30, 36, 30 Has the home visitor
48, 60
discussed the child's
ASQ:SE scores at [30, 36,
48, 60] months of age
with the primary
caregiver?
30, 36, 31 Please indicate
48, 60
whether the child's
ASQ:SE score at [30, 36,
48, 60] months of age was
above the established
referral score cutoff.
Note: Checked box =
scored above the cutoff
(i.e., did not meet socioemotional milestones)
30, 36, 32 (If home visitor
48, 60
checked the box for
question 31) Was the
child referred to relevant
community resources for
scoring above the referral
score cutoff on the
ASQ:SE?
30, 36,
48, 60
33 Was an appointment
made for further
screening/assessment of
the child referred to
relevant community
resources?
Additional guidance
We want to know if an appointment was made, either
by the home visitor or by the caregiver.
Examples of referrals include:
• Provide information about services
• Assist caregiver in accessing services
• Directly contact services with caregiver’s
permission
• Ongoing services provided by the agency
Services might include: health providers, Help Me
Grow, private therapy services, Follow Along Program,
Early Childhood Special Education (ECSE), infant
mental health providers
We want to know if an appointment was made, either
by the home visitor or by the caregiver.
40
30 months toddler – 66 months preschooler
Interval Question in the forms
All
34 BIOLOGICAL MOTHERS
ONLY: In the past 6
months, was the client
screened for the presence
of domestic violence
using the HFA Humiliation
Afraid Rape Kick Child
Survey (HARK-C)?
All
35 Did the screening tool
reveal evidence of
domestic violence?
All
36 Was a referral made to
relevant domestic
violence services and
noted in the client's
chart?
All
37 Was an intimate
partner violence safety
plan discussed,
completed, or reviewed?
All
38 Are you (client)
currently working?
All
39 What is your (client's)
household size?
Additional guidance
HARK-C: A cutoff score of 1 will be used as criteria for a
positive screen. Source: Sohal , et. al. BMC Family
Practice 2007 8:49.
Examples of referrals include:
• Confidentially provide information about
services
• Assist caregiver in accessing services
Follow the guidance of your own agency, or access
intimate partner violence resources in your
county/region.
“No, Not employed” indicates that the person is not
working for pay (this category may include, for
example, students, homemakers and those actively
seeking work but currently not employed).
Someone who receives disability and is not currently
working is “No, not employed”. Disability income is
counted in household income question.
A "household" is defined as a group of related or nonrelated individuals who are living together as one
economic unit sharing income and consumption of
goods and/or services (who stay there at least 4 nights
per week on average and contribute to the support of
the child or primary caregiver). Tenants/boarders shall
not be counted as members of the household.
A pregnant woman should be counted as two, taking
into consideration the unborn fetus(es).
Household size: total number of individuals sharing
income and consumption of goods and/or services.
41
30 months toddler – 66 months preschooler
Interval Question in the forms
All
40 Which category best
describes your (client's)
total annual household
income and benefits?
Additional guidance
A "household" is defined as a group of related or nonrelated individuals who are living together as one
economic unit sharing income and consumption of
goods and/or services (who stay there at least 4 nights
per week on average and contribute to the support of
the child or primary caregiver). Tenants/boarders shall
not be counted as members of the household.
Household size: total number of individuals sharing
income and consumption of goods and/or services.
"Income and benefits" should include annual earnings
from
•
•
•
•
•
•
•
work
rent from tenants/borders
cash assistance from friends/relatives
child support payments
TANF
Social Security (SSI/SSDI/OAI)
Unemployment Insurance)
Consider calculating household income in a similar way
you might be determining eligibility for other services
like MCH or TANF.
All
All
All
41 What is the highest
level of education you
(client) have attained?
42 In the past 6 months,
have you (client)
completed any
educational programs or
classes, such as grade
advancement, certificate,
ESOL, etc.?
43 Do you (client) have
health insurance?
Annual income data can be estimated from monthly
data (monthly income x 12).
ESOL = English for Speakers of Other Languages, also
sometimes referred to as English as a Second Language
(ESL) or English as a New Language (ENL)
It might help if the home visitor makes this question
more specific to the current time period. For example,
if the visit happens in March, the home visitor could
ask “Since September, have you completed…”
“02 No, uninsured” Includes clients who have applied
for insurance (pending)
Home visitors who encounter caregivers who do not
have health insurance coverage are encouraged to use
MNsure.org for coverage options available in
Minnesota state.
42
30 months toddler – 66 months preschooler
Interval Question in the forms
All
44 What is your major
medical care resource for
health insurance? (select
one or more)
All
45 Does your child have
health insurance?
All
46 What is your child's
major medical care
resource for health
insurance? (select one or
more)
Additional guidance
“02 Public insurance” includes any Minnesota Health
Care Programs (MHCP): Medical Assistance (MA),
Prepaid Medical Assistance Program (PMAP),
MinnesotaCare, Minnesota Family Planning Program
“02 No, uninsured” Includes clients who have applied
for insurance (pending)
“02 Public insurance” includes any Minnesota Health
Care Programs (MHCP): Medical Assistance (MA),
Prepaid Medical Assistance Program (PMAP),
MinnesotaCare, Minnesota Family Planning Program
43
Primary Caregiver Closure
Primary Caregiver Closure
Complete a closure form when
• Home visitor has tried consistently for several months to engage with the client and has been
unsuccessful
• The child and caregiver complete the program, as defined by the model
• Caregiver-Child dyad changes models
• Caregiver-Child dyad moves to another Local Health Department Site
• Child’s caregiver changes
o Example: Mother loses custody and home visits will now be with father
Question in the forms
1 Data entry staff (name)
2 Home visitor (name)
3 Site
3b Name of subcontracting agency, if applicable
4 Date of program closure
5 Total # home visits to-date
6 Child ID
7 Primary caregiver ID
8 Is there currently an active file at the lead Child
Protection Agency (CPA) of suspected
maltreatment for this child?
9 Was the suspected case of maltreatment
substantiated by the lead CPA?
10 Was the child of the substantiated case of
maltreatment a first-time victim, as reported by
lead CPA?
Additional guidance
The person doing the data entry into your system.
The health department site (county or city) where
the client lives.
Only fill this out if there is a subcontracting agency
performing family home visiting. If there is a new
subcontracting agency that doesn’t appear on this
list, contact [email protected]
Include the total number of visits with the
caregiver, including the current visit and any
previous FHV visits related to the current child.
This will likely require local public health to contact
other local agencies to access this information.
44
Primary Caregiver Closure
Question in the forms
11 Reason for program closure:
Additional guidance
Note the new option of “05 Transfer” added for
the 2015 evaluation.
Select “02 Stopped services for personal reason” if
program closure was due to a personal reason
elicited from the primary caregiver. Personal
reasons for program closure may include, but are
not limited to, the following: Returned to
work/school, refused nurse, dissatisfied with
services, pressure from peers or family, etc.
Select “03 Program unable to provide services” if
program closure was determined by program staff.
This option excludes program closure due personal
reasons elicited from the primary caregiver (see
above) or loss of follow-up (see below). Reasons
for closure that satisfy this criterion may include,
but are not limited to, the following: nurse
caseloads are overburdened, lack of staff safety,
language barriers, child is too old for services, etc.
Select “04 Loss of follow-up” if client moved out of
service area, unable to locate, excessive missed
visits, miscarriage/fetal death/infant death, child
no longer in family's custody, death of primary
caregiver, incarceration of primary caregiver, etc.
Select “05 Transfer” for clients who will be
receiving Family Home Visiting from another site in
Minnesota. For example, if a caregiver moves to
another part of the state and will continue Family
Home Visiting there.
45
Appendix: Terms and Acronyms
Appendix
Terms and Acronyms
Term
Definition
Caregiver-Child Dyad A set of one primary caregiver and one index child. A caregiver might be
part of more than one dyad if they had multiple births. A child might be
part of more than one dyad if their primary caregiver changed at any
time.
Index Child
The target child in an individual household who is under the care of the
primary caregiver. More than one index child can be identified (e.g., in
the case of twins, triplets, etc).
Model
The program that a site uses to implement home visiting. This includes
evidence-based models like Healthy Families America or Nurse-Family
Partnership. For the purposes of this evaluation and data analysis,
‘model’ also refers to whether a program is ‘other, ongoing’ or ‘other,
short-term/limited’.
Primary Caregiver
A person in the household who signed up to participate in the home
visiting program. The primary caregiver for a child can change for a
number of reasons, but at any one point a child should have one primary
caregiver specified. If the primary caregiver changes, the old one should
have a closure form filled out and the new one should have a caregiver
intake as well as a new child intake.
Acronym
ASQ
FHV
FHVRES
HFA
LPH
MCH
MDH
NCAST
NFP
TANF
Description
Ages and Stages Questionnaire
Family Home Visiting
Family Home Visiting Reporting and Evaluation System
Health Families America (specific model of family home visiting)
Local Public Health
Maternal & Child Health
Minnesota Department of Health
Nursing Child Assessment Satellite Training
Nurse Family Partnership (specific model of family home visiting)
Temporary Aid for Needy Families
46
Appendix: Reporting for the 2015 FHV Evaluation
Reporting for the 2015 FHV Evaluation
In 2015, the Minnesota Department of Health (MDH) Family Home Visiting (FHV)
Evaluation will collect individual-level data on a quarterly basis. Local public health
departments will submit data into the Family Home Visiting Reporting and Evaluation
System (FHVRES), which uses the secure MEDSS (Minnesota Electronic Disease
Surveillance System) to store public health data.
As of January 1st, 2015, LPH FHV programs will collect data per the variables and questions
on the January 2015 Family Home Visiting Evaluation Forms. If a LPH’s data collection
system is still in the process of building the January 2015 FHV Evaluation into their data
collection system, the LPH’s FHV program will collect the data on the paper forms and enter
the data into their system when it is ready. If a LPH FHV program is using a data collection
system that is unable to implement the 2015 FHV Evaluation, the LPH FHV program will use
MDH’s Interactive HTML Forms.
What to Submit
MDH is collecting data on FHV clients served in 2015 that meet the requirements of MN
State Statute 145A.17 (e.g., families at or below 200% of federal poverty guidelines, received
a public health nursing assessment by a public health nurse, services are offered for families
to accept or reject, etc.).
FHV Evaluation data submitted includes any caregiver-child sets1 that were open at any time
in 2014 or 2015 (see exception of MIECHV clients below). This means, for example, if a
client had an intake in 2013 and was closed in 2014 we would need the entire set of visits.
EXCEPTION: For MIECHV sets, the data must always be submitted regardless of date of
visit to capture 2012-2013 data required by HRSA. Below are examples of FHV sets to
include or not include in 2015 data submissions:
Example Set
Intake
Closure
Include in
2015 Data
Submissions
Client #1
March 1st, 2014
N/A (still open)
Yes
Client #2
January 1st, 2013
December 31st, 2014
Yes
Client # 3
March 1st, 2013
October 31st 2013
No
47
Appendix: Reporting for the 2015 FHV Evaluation
Only Set #3 is not included in the submission because it was closed before January 1st, 2014
1
A set is the FHV evaluation record for any Caregiver-child dyad from Caregiver Intake through closure.
Which Forms to Complete
Regardless of FHV Model, all Caregiver-child dyads require a Caregiver Intake, and
eventually a Child Intake and Closure form. For clients enrolled in NFP, HFA, or long term,
ongoing FHV models additional forms are required depending on whether the appropriate age
interval for the dyad is reached. Clients enrolled in short-term/limited FHV will only need to
do the additional forms if the visit(s) fall within the age interval for a form.
All forms, from Caregiver Intake to Closure, must be filled out for each child. In addition,
clients will need a new Caregiver & Child Intake form for the following situations:
-
Caregiver-Child dyad changes FHV model
Caregiver-Child dyad moves to another local health department’s jurisdiction
(i.e. changes Site)
Caregiver changes for a child
Caregiver-Child dyad restarts an FHV program for which they have already
had a closure form filled out.
For clients enrolled in NFP, HFA, or “other, ongoing” FHV services, all FHV evaluation
forms are completed for the time frame that the client/child received those services. Data
should be collected within two months before or two months after the specified interval. For
example, home visitors can complete the six month form two months before the child’s sixth
month birthday until two months after the child’s sixth month birthday. Exceptions are the
two intake forms. Also, consider the appropriate age of the child as required by the
screening tools such as the ASQ-3 and the ASQ: SE. If a child’s age is too young or too old
to administer a particular tool during the interval specified in the evaluation form, please still
report data for the rest of the form if the visit is within the two months before or two months
after the specified interval.
For caregivers & children enrolled in NFP, the LPH agencies should complete all forms
required by the NFP model. IN ADDITION, the NFP Supplemental forms should be
completed in ETO when the Caregiver/Child reach the appropriate interval
For dyads enrolled in HFA, NFP, or Other, Ongoing FHV, MDH expects that all questions in the 2015 FHV
Evaluation be answered if applicable. Short-term/limited dyads may not be required to answer all the
questions of the 2015 FHV Evaluation, but MDH expects the answers to be reported if the home visitor
does collect the data as part of their FHV intervention. For ease of use, required questions for shortterm/limited dyads are marked with an asterisk (*) on the 2015 FHV Evaluation forms.
48
Appendix: Reporting for the 2015 FHV Evaluation
Where to submit
In 2015, FHV Evaluation data will be uploaded into the Family Home Visiting Reporting and Evaluation
System (FHVRES). In order to upload files, users will need to be a registered user of the Minnesota
Electronic Disease Surveillance System (MEDSS), and have the appropriate MEDSS credentials. This
process will be described in another document at a later date.
For local public health users of the Metro Alliance for Healthy Families (MAHF) database, all
families with data entered into MAHF will be submitted directly to MDH by MAHF. For local
public health users of NFP-ETO, data entered into NFP-ETO will be submitted directly to
MDH.
All other data files are to be submitted by the local health department or contracting agency to
FHVRES.
For technical assistance with extracting data from your data collection system for submission,
please contact your data collection system vendor (list below).
•
•
•
•
•
•
CareFacts: Amy Anderson: [email protected]
Metro Alliance for Healthy Families (MAHF): Scott Jara: [email protected]
MDH Interactive HTML Forms: Fred Radmer: [email protected]
Nightingale Notes: Stacy Coleman: [email protected]
Nurse-Family Partnership (NFP ETO): Not applicable as data from NFP
ETO is submitted directly to MDH by NFP.
PH-DOC: Support Team: [email protected]
When to Submit
2015 Reporting Schedule:
Quarter
End of Quarter
Date submission deadline
1st
March 31, 2015
April 10, 2015
2nd
June 30, 2015
July 10, 2015
3rd
September 30, 2015
October 12, 2015
4th
December 31, 2015
January 11, 2015
49
Appendix: Reporting for the 2015 FHV Evaluation
Local health departments are encouraged to submit data monthly once FHVRES is operational and local
data systems can accommodate the upload of data to MDH to 1) take advantage of the features that
help identify missing and invalid data and 2) more frequently monitor benchmarks.
Collection of Name & Address Identifiers
LPH FHV programs will report name and address identifiers in their data submissions starting
in 2015 when they have the appropriate data use and privacy agreements in place. All LPH
FHV programs will submit all identifiers on clients enrolled after October 1, 2015, at which
time all necessary data use and privacy agreements will be expected to be in use with clients.
Clients may still opt-out of allowing the local health department to submit some or all of their
data to MDH. Local public health departments should track clients who opt out so that
annualized aggregate totals of key demographics can be tabulated and submitted to MDH for
reporting to the legislature.
50
Appendix: 2015 FHV Evaluation: Data to Report to the MDH
2015 FHV Evaluation: Data to Report to the MDH
Local public health family home visiting programs provide a variety of services to maternal and child
health clients. This document reflects Statute M.S. 145A.17 and serves as a guide to local programs in
determining what data is collected and reported to the Minnesota Department of Health as part of the
state family home visiting evaluation.
1. Short-term/limited FHV**
Includes those who received a Public Health
Nursing assessment by a PHN* for the
purpose of determining need for enrollment
in an ongoing FHV program or identifying
and achieving short-term FHV goals.
As local data systems are able to do so, MDH
will also collect data from local FHV
programs on MDH FHV Evaluation
benchmark measures as defined by MDH, to
the extent local programs collect those data
(as required by models, funding source,
etc.).
2. HFA, NFP & Other Ongoing FHV**
Includes those who received a Public Health
Nursing assessment by a PHN and were then
enrolled in an ongoing Family Home Visiting
Program to achieve long-term outcomes.*
MDH will collect data from local FHV programs
on MDH FHV Evaluation benchmark measures
and demographics as defined by MDH, to the
extent local programs collect those data (as
required by models, funding source, etc.).
* Assessment: A public health nursing assessment by a Public Health Nurse to determine family income
and level of family risk including but not limited to child maltreatment (refer to Family Home Visiting
Statute M.S. 145A.17 for additional risk factors).
** Family Home Visiting Program: A family home visiting (FHV) program whose goals are to foster
healthy beginnings, improve pregnancy outcomes, promote school readiness, prevent child abuse and
neglect, reduce juvenile delinquency, promote positive parenting and resiliency in children, and
promote family health and economic self-sufficiency for children and families. Local FHV programs
collect and submit demographic and benchmark data to the Minnesota Department of Health as part of
the Family Home Visiting Evaluation. Per Statute M.S. 145A.17, programs must begin prenatally
whenever possible and must be targeted to families with one or more risks as defined by the statute.
51
Appendix: List of Validated Screening and Assessment Tools Used in Family Home Visiting (FHV)
Evaluation
List of Validated Screening and Assessment Tools Used in Family Home Visiting
(FHV) Evaluation
Edinburg Postnatal Depression Scale (EPDS)
• Interval: 0-3 months postpartum
• Positive screen cutoff score: 10 or greater
Patient Health Questionnaire (PHQ-2, PHQ-9)
• Interval: 0-3 months postpartum
• Positive screen cutoff score: 10 or greater
Home Safety Checklist (MDH)
• Interval: 1st postpartum visit; 6 months postpartum
• Available online at: http://www.health.state.mn.us/divs/cfh/
program/fhv/homevisitor.cfm#tools . An equivalent checklist is acceptable.
Well-Child Care Checkup Schedule
• Interval: 50% completion of checkups at 12 and 24 months postpartum
• Accepted schedules: Follow-along Program; AAP Recommendations for Preventive Pediatric Health
Care; Minnesota C&TC Early and Periodic Screening, Diagnosis & Treatment Schedule of Age-Related
Screening Standards
HFA Humiliation, Afraid, Rape, Kick Child Survey (HARK-C)
• Interval: Prenatal to 3 months postpartum
• Positive screen cutoff score: 1 or greater
NFP Relationship Assessment (Proprietary)
• Interval: Prenatal to 3 months postpartum
• Positive screen cutoff score: A ‘Yes’ response to questions 1, 2, 9, 11, or 13 on the NFP Relationship
Assessment form will be used as criteria for a positive screen
Intimate Partner Violence Safety Plan
• Interval: 6 months postpartum
• No formal safety plan; use any safety plan.
NCAST Parent-Child Interaction (PCI) Teaching Scale
• Interval: First assessment at 0-3 months postpartum; 12 months postpartum
Ages & Stages Questionnaires (ASQ-3)
• Interval: 4 months postpartum; 10 or 12 months postpartum
Ages & Stages Questionnaire: Social-Emotional (ASQ:SE)
• Interval: 12 months postpartum
52
Appendix: Maternal Depression Screening Algorithm (EPDS)
Maternal Depression Screening Algorithm
Edinburgh Postnatal Depression Scale (EPDS)
From the prenatal period to greater than one year postpartum
1. Recommendations for Screening:
• Screen on program entry in pregnancy
• Screen at 28-32 weeks gestation
• Screen at 4-6 weeks postpartum
• Screen at 4, 6 and 8 months postpartum
• Screen as PRN prenatally, postpartum and by mothers of older children based on clinical
judgment
2. EPDS score:
Is the score 10 or greater, or is there a positive answer on item number 10? If yes refer to 3b. If no refer
to 3a.
3a. the EPDS score is less than 10 and there is a negative answer on item number 10.
Does the clinical judgment warrant further assessment? If yes, refer to 4c. if no refer to 4a.
3b. the EPDS score is 10 or greater or there is a positive answer on item number 10.
Is there imminent danger? Client expresses thoughts or feelings of hurting self, children or others. If yes
refer to 4b. If no refer to 4c.
4a. No immediate referral is needed.
• Provide materials on maternal depression if not previously given
• Educate on mental health wellness
• Assess personal support resources and provide information on support resources in
community
• Re-screen at subsequent visits or PRN
• See document “What’s Next” for more information and resources
4b. Refer to Crisis Intervention Algorithm
See on separate page.
4c. Provide referral information, education and support
Refer to 5.
5. Refer to document “What’s Next” for expanded information
53
Appendix: Maternal Depression Screening Algorithm (EPDS)
• Request or renew client’s permission to contact her obstetrician or primary care provider
and/or current therapist following the protocol for your agency regarding sharing of information
• Provide the client with information on mental health professional providers in your area and
encourage appointment with a mental health professional; assist with the referral call if needed
• Assess the client’s level of social support (ex. client’s partner, other family members, friends,
faith community, and childcare providers) and explore ways to increase social support if needed.
Include these persons in ongoing conversations as allowed by client
• When client is willing, provide education on depression and mental health wellness
• Provide emotional support by acknowledging that what the client feels is real and important
• Assure client understands how to seek emergency assistance if depression worsens or client
develops thoughts of self-harm or harm of others; speak frankly about these thoughts as
symptoms of the disorder
• Re-screen at subsequent visits or PRN; engage client in ongoing conversation about symptoms
and experience; reassure client that you will work with them to address ongoing needs
(Edited by Cindy Kellett, PHN, DNP Student, University of Minnesota for the Minnesota Department of
Health). Developed by the El Paso County Department of Health & Environment Nurse -Family
Partnership Program - Adopted by the work of Renquist, J. & Barnekow, K. (2008) Wisconsin Infant
Mental Health Conference)
*Cox, J.L., Holden, J.M., and Sagovsky, R. (1987). Detection of postnatal depression: Development of the
10-item Edinburgh
Postnatal Depression Scale. British Journal of Psychiatry, 150,782-786.
*Wisner, K.L; Parry, B. L.; Piontek, C. M. (2002). Postpartum Depression. N Engl J Med 347(3), 194-199.
*Cox, J.L; Chapman, G.; Murray, D.; Jones, P. (1995). Validation of the Edinburgh postnatal depression
scale (EPDS) in non-postnatal women. Journal of Affective Disorders, 39, 185-189.
54
Appendix: Maternal Depression Screening Algorithm (PHQ-9)
Maternal Depression Screening Algorithm
PHQ-9
From the prenatal period to greater than one year postpartum
1. Recommendations for Screening:
• Screen on program entry in pregnancy
• Screen at 28-32 weeks gestation
• Screen at 4-6 weeks postpartum
• Screen at 4, 6 and 8 months postpartum
• Screen as PRN prenatally, postpartum and by mothers of older children based on clinical
judgment
2. PHQ-9 score:
Is the score 15 or greater, or is there a positive answer on item number 9? If yes refer to 3b. If no refer
to 3a.
3a. Does clinical judgment warrant further assessment?
If no refer to 4a. If yes refer to 4c.
3b. Is there imminent danger?
Client expresses thoughts or feelings of hurting self, children or others. If yes refer to 4b. If no refer to
4c.
4a. No immediate referral is needed.
• Provide materials on maternal depression if not previously given
• Educate on mental health wellness
• Assess personal support resources and provide information on support resources in
community
• Re-screen at subsequent visits or PRN
• See document “What’s Next” for more information and resources
4b. Refer to Crisis Intervention Algorithm
See on separate page.
4c. Provide referral information, education and support
Refer to 5.
5. Refer to document “What’s Next” for expanded information
55
Appendix: Maternal Depression Screening Algorithm (PHQ-9)
• Request or renew client’s permission to contact her obstetrician or primary care provider
and/or current therapist following the protocol for your agency regarding sharing of information
• Provide the client with information on mental health professional providers in your area and
encourage appointment with a mental health professional; assist with the referral call if needed
• Assess the client’s level of social support (ex. client’s partner, other family members, friends,
faith community, and childcare providers) and explore ways to increase social support if needed.
Include these persons in ongoing conversations as allowed by client
• When client is willing, provide education on depression and mental health wellness
• Provide emotional support by acknowledging that what the client feels is real and important
• Assure client understands how to seek emergency assistance if depression worsens or client
develops thoughts of self-harm or harm of others; speak frankly about these thoughts as
symptoms of the disorder
• Re-screen at subsequent visits or PRN; engage client in ongoing conversation about symptoms
and experience; reassure client that you will work with them to address ongoing needs
(Edited by Cindy Kellett, PHN, DNP Student, University of Minnesota for the Minnesota Department of
Health). Developed by the El Paso County Department of Health & Environment Nurse -Family
Partnership Program - Adopted by the work of Renquist, J. & Barnekow, K. (2008) Wisconsin Infant
Mental Health Conference)
Kroenke, K.; Spitzer, R. L.; Williams, J. B. W.(2001) PHQ-9. Journal of General Internal Medicine, 16(9):
606–613.
Wisner, K.L; Parry, B. L.; Piontek, C. M. (2002). Postpartum Depression. N Engl J Med 347(3), 194-199.
56
Appendix: Crisis Intervention Algorithm
Crisis Intervention Algorithm
It is determined that mother/client is suicidal or homicidal, and there is imminent danger
1. Step One
• Call local emergency resources
• Stay with client until arrangements are made for client safety
• Contact your supervisor
2. Refer to local resource information sheet
3. Collaborate with mother for care of child/ren
• Consider friends, relatives, neighbors
• Local emergency shelter if no other options
• Assist with arrangements as needed
4. Document the complete intervention including:
• Client condition
• Contacts made
• Arrangements made
• Time of events (example: called police at 4:15pm)
5. Contact care provider:
a. Primary care, obstetrician and/or mental health care provider to inform of situation
Follow-Up
1. Debrief with supervisor or coworker
2. Contact client next business day:
• Provide support
• Obtain updated status
• Plan for follow-up visits
3. On follow-up visit with client:
• Continue to evaluate mental health status
• Discuss experience
• Determine plan for mental health follow-up
• Stay focused on purpose of keeping baby and mom safe
4. Keep in touch with assigned therapist/ provider
Minimum monthly until mother is stable as determined by therapist/ mental health provider
5. Return to maternal screening algorithm
(Edited Cindy Kellett, DNP Student, University of Minnesota for MDH) Developed by the El Paso County
Department of Health & Environment Nurse -Family Partnership Program - Adopted by the work of
Renquist, J. & Barnekow, K. (2008) Wisconsin Infant Mental Health Conference)
Kroenke, K.; Spitzer, R. L.; Williams, J. B. W.(2001) PHQ-9. Journal of General Internal Medicine, 16(9):
606– 613.
Wisner, K.L; Parry, B. L.; Piontek, C. M. (2002). Postpartum Depression. N Engl J Med 347(3), 194-199.
57
Appendix: What is Next? Positive Screen for Depression
What is Next? Positive Screen for Depression
What does a positive screen mean?
•
•
•
•
This woman is suffering from many of the symptoms of depression.
It does NOT mean she has depression.
Only a mental health professional or primary care provider can determine a diagnosis of depression.
There is a 25 to 40% chance that she will be diagnosed with depression. The screening tools are
designed to over-identify because of the potentially life-threatening consequences of depression.
How do I know if I should make a referral to a mental health professional?
• A referral is necessary for scores of 13 or more on the EPDS or 15 or more on the PHQ-9.
• A score of 10 to 12 on the EPDS or 5 - 14 on PHQ-9 is a sign of possible depression and may not
require immediate referral; use your professional judgement and provide interventions described in
the next section.
• Any positive score on item #10 on the EPDS or #9 on the PHQ-9 requires a referral.
• Ask specific questions:
1. “Do you have any thoughts of harming yourself?”
Any person who is thinking about harming themself or others should talk to a mental
health professional, regardless of the EPDS score.
2. If she answers yes to thoughts of self-harm in any way, then ask,;
“Do you have a plan to hurt yourself (e.g. pills)?
If there is any kind of plan of self harm or harm to others, refer to psychiatric
emergency services immediately.
Assist in arrangements for someone to be with her and for transportation to the
emergency room, hospital or clinic
•
•
If your client thinks she may be depressed or is exhibiting symptoms of depression, extreme anger,
or anxiety, refer even if she did not screen positive. A majority of women who are depressed will
screen positive on these tools but some may not
Offer to help to make the first call to the mental health provider to facilitate access to mental health
services
What else can I do?
• Support your client by listening and validating that what she is feeling is real, is not her fault, and
she is not alone (at least 1 in 5 women will experience depression after childbirth). Inform her that
treatment is very effective and that she will feel better in time.
The following is an example of what you might say:
58
Appendix: What is Next? Positive Screen for Depression
“Based on what you’ve told me and your score, I am concerned that you have some
symptoms of depression. What you are feeling is real and it is not your fault. It can be hard to
feel this way when you have a baby/young child. Depression is partly due to an imbalance of
chemicals in your body and things that cause stress in your life. There are things you can do to
feel better. Let’s talk about some ideas that might work for you.”
•
•
•
•
•
•
•
•
Your support and validation is very powerful and can make a difference in whether this client will
seek help and care for herself.
Educate her about depression verbally and leave brochures or handouts about depression.
Encourage an appointment with her primary care provider (Obstetrician, Family Physician, Nurse
Midwife, etc.) to rule out other medical conditions or for treatment of depression if that is indicated.
Assist client with making an appointment and securing transportation if this is needed.
Inform her of mental health professionals in the area and provide contact information. Assist client
with making an appointment and securing transportation if this is needed.
Assess level of social support. Who can she rely on for childcare for respite? Who can she talk to?
Social support includes her partner, family, friends, neighbors, faith community, child care providers,
etc.
Offer a list of other community resources for support such as local pastors, parent groups such as
ECFE, faith community, neighbors, friends, volunteer groups, local support groups, etc.
Educate on the importance of self-care for physical and mental wellness including:
o Take care of your body by caring for physical illness and taking prescribed medications
o Good balanced nutrition
o Limit caffeine
o Avoid mood altering drugs
o Adequate sleep
o Adequate exercise
o Do something everyday to make yourself feel competent and in control
o Take time away for relaxation and enjoyable activities
o Participating in hobbies and interests outside of daily work and family obligations
o Talk to supportive family and friends
o Regular visits with primary care provider for physical exam and assessment
Inform of emergency resources in the area if depression symptoms worsen or thoughts of self-harm
or harm of others develops.
o
•
Crisis lines - Crisis Connection at 866-379-6363; TTY 612-379-6377 or call 911
o Hospital emergency rooms, crisis centers
o Outpatient clinics for daytime hours
Help client make a personal plan of action and arrange to follow up with a phone call in a few hours
or days to support and encourage follow-through.
59
Appendix: What is Next? Positive Screen for Depression
What about the Baby?
Mother’s who experience depression often experience a profund sense of emptiness, including a loss of
interest and pleasure in being with the baby. Depression may impact the mother’s ability to pick up on
subtle cues expressed by the infant which can have a significant impact on the parent child interaction.
Consider the following strategies:
• NCAST Parent Child Interaction Scales (Teaching and Feeding)
• Referral to an Infant Mental Health clinician
• Provide ongoing assessment, support, and intervention that is focused on the infant parent
relationship
• Collaborate with other clinicians to support treatment of maternal and/or infant
disorders/delays
(Edited by Cindy Kellett, PHN, DNP Student, University of Minnesota for MDH). Developed by the El
Paso County Department of Health & Environment Nurse -Family Partnership Program - Adopted by the
work of Renquist, J. & Barnekow, K. (2008) Wisconsin Infant Mental Health Conference)
J. Kevin Nugent – What newborn babies and their parents would like us to know (2014). 15th Biennial
ncast programs Institute
Other Resources:
Mother-Baby HopeLine – 612-873-HOPE (4673) – this is a free telephone support service for pregnant
women/parents of young children as well as providers. Calls are not answered immediately. Callers will
be asked to leave a message and a mental health staff member will call back within 2 business days.
Minnesota Department of Health Postpartum depression education materials
http://www.health.state.mn.us/divs/cfh/topic/pmad/materials.cfm
National Alliance on Mental Illness (NAMI) provides educational fact sheets, support, publications
http://www.namihelps.org/education/fact-sheets.html
National Institue of Mental Health (NIH) provides information on mental health topics
http://www.nimh.nih.gov/health/topics/index.shtml
National Suicide Hopeline: 800.784.2433
http://www.hopeline.com
National Suicide Prevention Lifeline: 800.273.8255 http://www.suicidepreventionlifeline.org
Pregnancy Postpartum Support Minnesota Resource List: http://www.ppsupportmn.org/
PPSM HelpLine (612) 787-PPSM or [email protected] . For questions, resources, and phone
support, please call the PPSM Helpline or visit www.ppsupportmn.org. All calls are taken by a trained
mental health professional. Support and information provided by peer volunteers 7days a week. The
PPSM HelpLine is not a crisis phone line
60
Appendix: FHV MN State Statute
FHV MN State Statute
145A.17 FAMILY HOME VISITING PROGRAMS.
Subdivision 1. Establishment; goals.
The commissioner shall establish a program to fund family home visiting programs designed to
foster healthy beginnings, improve pregnancy outcomes, promote school readiness, prevent child abuse
and neglect, reduce juvenile delinquency, promote positive parenting and resiliency in children, and
promote family health and economic self-sufficiency for children and families. The commissioner shall
promote partnerships, collaboration, and multidisciplinary visiting done by teams of professionals and
paraprofessionals from the fields of public health nursing, social work, and early childhood education. A
program funded under this section must serve families at or below 200 percent of the federal poverty
guidelines, and other families determined to be at risk, including but not limited to being at risk for child
abuse, child neglect, or juvenile delinquency. Programs must begin prenatally whenever possible and
must be targeted to families with:
(1) adolescent parents;
(2) a history of alcohol or other drug abuse;
(3) a history of child abuse, domestic abuse, or other types of violence;
(4) a history of domestic abuse, rape, or other forms of victimization;
(5) reduced cognitive functioning;
(6) a lack of knowledge of child growth and development stages;
(7) low resiliency to adversities and environmental stresses;
(8) insufficient financial resources to meet family needs;
(9) a history of homelessness;
(10) a risk of long-term welfare dependence or family instability due to employment barriers;
(11) a serious mental health disorder, including maternal depression as defined in section 145.907;
or
(12) other risk factors as determined by the commissioner.
Subd. 2.
[Repealed, 1Sp2003 c 14 art 8 s 32]
Subd. 3.Requirements for programs; process.
(a) Community health boards and tribal governments that receive funding under this section must
submit a plan to the commissioner describing a multidisciplinary approach to targeted home visiting for
61
Appendix: FHV MN State Statute
families. The plan must be submitted on forms provided by the commissioner. At a minimum, the plan
must include the following:
(1) a description of outreach strategies to families prenatally or at birth;
(2) provisions for the seamless delivery of health, safety, and early learning services;
(3) methods to promote continuity of services when families move within the state;
(4) a description of the community demographics;
(5) a plan for meeting outcome measures; and
(6) a proposed work plan that includes:
(i) coordination to ensure nonduplication of services for children and families;
(ii) a description of the strategies to ensure that children and families at greatest risk receive
appropriate services; and
(iii) collaboration with multidisciplinary partners including public health, ECFE, Head Start,
community health workers, social workers, community home visiting programs, school districts, and
other relevant partners. Letters of intent from multidisciplinary partners must be submitted with the
plan.
(b) Each program that receives funds must accomplish the following program requirements:
(1) use a community-based strategy to provide preventive and early intervention home visiting
services;
(2) offer a home visit by a trained home visitor. If a home visit is accepted, the first home visit must
occur prenatally or as soon after birth as possible and must include a public health nursing assessment
by a public health nurse;
(3) offer, at a minimum, information on infant care, child growth and development, positive
parenting, preventing diseases, preventing exposure to environmental hazards, and support services
available in the community;
(4) provide information on and referrals to health care services, if needed, including information on
and assistance in applying for health care coverage for which the child or family may be eligible; and
provide information on preventive services, developmental assessments, and the availability of public
assistance programs as appropriate;
(5) provide youth development programs when appropriate;
(6) recruit home visitors who will represent, to the extent possible, the races, cultures, and
languages spoken by families that may be served;
(7) train and supervise home visitors in accordance with the requirements established under
subdivision 4;
(8) maximize resources and minimize duplication by coordinating or contracting with local social
and human services organizations, education organizations, and other appropriate governmental
entities and community-based organizations and agencies;
62
Appendix: FHV MN State Statute
(9) utilize appropriate racial and ethnic approaches to providing home visiting services; and
(10) connect eligible families, as needed, to additional resources available in the community,
including, but not limited to, early care and education programs, health or mental health services, family
literacy programs, employment agencies, social services, and child care resources and referral agencies.
(c) When available, programs that receive funds under this section must offer or provide the family
with a referral to center-based or group meetings that meet at least once per month for those families
identified with additional needs. The meetings must focus on further enhancing the information,
activities, and skill-building addressed during home visitation; offering opportunities for parents to meet
with and support each other; and offering infants and toddlers a safe, nurturing, and stimulating
environment for socialization and supervised play with qualified teachers.
(d) Funds available under this section shall not be used for medical services. The commissioner
shall establish an administrative cost limit for recipients of funds. The outcome measures established
under subdivision 6 must be specified to recipients of funds at the time the funds are distributed.
(e) Data collected on individuals served by the home visiting programs must remain confidential
and must not be disclosed by providers of home visiting services without a specific informed written
consent that identifies disclosures to be made. Upon request, agencies providing home visiting services
must provide recipients with information on disclosures, including the names of entities and individuals
receiving the information and the general purpose of the disclosure. Prospective and current recipients
of home visiting services must be told and informed in writing that written consent for disclosure of data
is not required for access to home visiting services.
(f) Upon initial contact with a family, programs that receive funding under this section must receive
permission from the family to share with other family service providers information about services the
family is receiving and unmet needs of the family in order to select a lead agency for the family and
coordinate available resources. For purposes of this paragraph, the term "family service providers"
includes local public health, social services, school districts, Head Start programs, health care providers,
and other public agencies.
Subd. 4.Training.
The commissioner shall establish training requirements for home visitors and minimum
requirements for supervision. The requirements for nurses must be consistent with chapter 148. The
commissioner must provide training for home visitors. Training must include the following:
(1) effective relationships for engaging and retaining families and ensuring family health, safety,
and early learning;
(2) effective methods of implementing parent education, conducting home visiting, and promoting
quality early childhood development;
(3) early childhood development from birth to age five;
(4) diverse cultural practices in child rearing and family systems;
63
Appendix: FHV MN State Statute
(5) recruiting, supervising, and retaining qualified staff;
(6) increasing services for underserved populations; and
(7) relevant issues related to child welfare and protective services, with information provided being
consistent with state child welfare agency training.
Subd. 4a.
Home visitors as MFIP employment and training service providers.
The county social service agency and the local public health department may mutually agree to
utilize home visitors under this section as MFIP employment and training service providers under section
256J.49, subdivision 4, for MFIP participants who are: (1) ill or incapacitated under section 256J.425,
subdivision 2; or (2) minor caregivers under section 256J.54. The county social service agency and the
local public health department may also mutually agree to utilize home visitors to provide outreach to
MFIP families who are being sanctioned or who have been terminated from MFIP due to the 60-month
time limit.
Subd. 5.
Technical assistance.
The commissioner shall provide administrative and technical assistance to each program, including
assistance in data collection and other activities related to conducting short- and long-term evaluations
of the programs as required under subdivision 7. The commissioner may request research and
evaluation support from the University of Minnesota.
Subd. 6.
Outcome and performance measures.
The commissioner shall establish measures to determine the impact of family home visiting
programs funded under this section on the following areas:
(1) appropriate utilization of preventive health care;
(2) rates of substantiated child abuse and neglect;
(3) rates of unintentional child injuries;
(4) rates of children who are screened and who pass early childhood screening;
(5) rates of children accessing early care and educational services;
(6) program retention rates;
(7) number of home visits provided compared to the number of home visits planned;
64
Appendix: FHV MN State Statute
(8) participant satisfaction;
(9) rates of at-risk populations reached; and
(10) any additional qualitative goals and quantitative measures established by the commissioner.
Subd. 7.
Evaluation.
Using the qualitative goals and quantitative outcome and performance measures established
under subdivisions 1 and 6, the commissioner shall conduct ongoing evaluations of the programs funded
under this section. Community health boards and tribal governments shall cooperate with the
commissioner in the evaluations and shall provide the commissioner with the information necessary to
conduct the evaluations. As part of the ongoing evaluations, the commissioner shall rate the impact of
the programs on the outcome measures listed in subdivision 6, and shall periodically determine whether
home visiting programs are the best way to achieve the qualitative goals established under subdivisions
1 and 6. If the commissioner determines that home visiting programs are not the best way to achieve
these goals, the commissioner shall provide the legislature with alternative methods for achieving them.
Subd. 8.
Report.
By January 15, 2002, and January 15 of each even-numbered year thereafter, the commissioner
shall submit a report to the legislature on the family home visiting programs funded under this section
and on the results of the evaluations conducted under subdivision 7.
Subd. 9.
No supplanting of existing funds.
Funding available under this section may be used only to supplement, not to replace, nonstate
funds being used for home visiting services as of July 1, 2001.
History:
1Sp2001 c 9 art 1 s 53; 2002 c 379 art 1 s 113; 2007 c 147 art 17 s 1; 2009 c 79 art 2 s 8; 1Sp2011 c
9 art 2 s 22; 2013 c 108 art 12 s 49
Copyright © 2014 by the Revisor of Statutes, State of Minnesota. All rights reserved.
65
Appendix: TANF Grant Guidelines
TANF Grant Guidelines
January 2008
The Federal Temporary Assistance for Needy Families (TANF) block grant allows states to allocate
resources for a broad array of services that promote the four purposes of the TANF statute: assisting
needy families so children may be cared for at home, ending dependence of needy families on
government benefits by promoting work and marriage, reducing non-marital pregnancies and
encouraging the formation and maintenance of two parent families. In Minnesota, TANF funds allocated
through the Local Public Health Act can be used for eligible program services including non-medical
home visiting for families, Women’s Infants and Children (WIC) clinic services, and youth development:
focus on reducing out of wedlock births.
These TANF Grant Guidelines provide local public health agencies guidance regarding eligible services,
eligible populations, determination and documentation of eligibility, matching requirements, allowable
program and administrative costs, reporting requirements and intervention examples. The Federal
Poverty Guidelines referenced in this document are produced by the Department of Health and Human
Services (HHS) and are updated on an annual basis. The most current Federal Poverty Guidelines may be
accessed by going to http://aspe.hhs.gov/poverty.
Eligible Program Services
Includes services provided by a professional staff in one or more of the following program areas:
non-medical home visiting for families, WIC clinic services, or group youth development
activities focusing on reducing out of wedlock births.
a. Non-Medical Home Visiting for Families
Interventions designed to foster healthy beginnings, improve pregnancy
outcomes, promote school readiness, prevent child abuse and neglect, reduce
juvenile delinquency, promote positive parenting and resiliency in children, and
promote family health and economic self-sufficiency for children and families.
TANF funds can not be used to fund home visits that provide medical services
such as home health care.
b. Women’s, Infants and Children (WIC) Clinic Services
Interventions that address nutritional issues of women, infants, and young
children through WIC clinic services. No more than forty-nine percent (49%) of the
total annual award of TANF funds may be used for WIC services.
c. Youth Development: Focus on Reducing Out of Wedlock Births
Interventions in this service area should be evidenced based or promising practice
strategies that address the risk and/or protective factors contributing to teen
pregnancy and involve youth and their parents in the development and
66
Appendix: TANF Grant Guidelines
implementation of activities. The need for interventions in this area should be
developed based on a needs assessment of the community. Activities should be
coordinated with other community efforts, build partnerships to mobilize the
community in addressing the issue of teen pregnancy and must occur in a group
setting.
Eligible Populations
Family home visiting and WIC services using TANF funds may only be provided to families who
are receiving federal funded MFIP or have an adjusted gross income at or below 200% of federal
poverty guidelines and who are U.S. citizens or eligible non-citizens and who live in an eligible
household (See III.B.2). Eligibility for services must be documented in the individual’s case
record. Group youth development activities focused on reducing out of wedlock births do not
require documentation that youth meet income and citizen status, but activities should be
directed to eligible populations.
Determination and Documentation of Eligibility for Family Home Visiting or WIC
Clinic Services
To receive family home visiting or WIC services funded by TANF dollars, a family must be
receiving federally funded MFIP OR have an adjusted gross annual household income equal to or
less than 200% of federal poverty guidelines, be a U.S. Citizen or an eligible non-citizen, and live
in a household comprised of a minor child or a pregnant woman. Eligibility determinations must
occur at least once every 12 months. An agency providing services must determine whether the
participant meets the income and citizen eligibility criteria and document in their record the
participant’s eligibility. See Section III D for documentation guidelines.
Automatic Eligibility Screening
A family receiving federally funded Minnesota Family Investment Program (MFIP) can
be determined automatically eligible for home visiting or WIC services.
If a family is receiving state funded MFIP, they are NOT automatically eligible for
TANF funded home visiting or WIC services.
Information on whether a recipient is receiving federal or state funded MFIP can only be
obtained by contacting the local social service agency.
Non Automatic Eligibility Screening
If a family is not receiving federally funded MFIP, eligibility screening is required.
Family composition, citizen status, household size and income levels are critical
components of the eligibility screening process.
67
Appendix: TANF Grant Guidelines
Eligible households:




A household must consist of either:
A pregnant woman
Parent(s) or guardian(s) and a child or children under age 18
Parent(s) or guardian(s) and a child or children age 18 and 19 who attend
secondary school
Household size determination
Household is defined as a group of related or non-related individuals who are
living together as one economic unit sharing income and consumption of goods
and/or services. The total number of individuals sharing income and consumption
of goods and/or services comprises the household size.
It is possible that more than one household lives under one roof. An example:
Residents of a homeless facility or an institution are not considered members of a
single household. The following guidelines should be used to determine
household size.
•
If the family to be provided services is living without economic support from
the other persons in the same residence, the family to be provided services is
considered a separate household and only the members of the family unit to be
provided services is counted to determine family size. However, if the family
unit is fully sharing resources, then all the members residing in the household
are counted in determining family size. If the family unit is only receiving
temporary shelter (a place to sleep at night), the individuals making up that
family unit would be considered a separate household. If the family unit is
providing services (e.g. child care) in exchange for room and board, the
family can be counted as a separate household.
•
A family who has little or no income to report should be asked to explain
her/his situation to determine whether there is a household in which s/he
should be counted, or if any public assistance, union benefits, unemployment
or other sources of income are being received.
•
A child who resides in more than one household as a result of joint custody
shall be considered part of the household of the guardian who is receiving
services. If, for example, a mother and child live together and receive child
support payments from a father who does not live with them, the child is
counted in the mother’s household size and not the father’s. When
determining income, the mother must count the child support payment as
income. If the father’s household also requests TANF funded services, the
father may not deduct child support payments for the reported income from
his household, since deductions are not allowed. However, all children being
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supported may be counted as part of the household.
•
A foster child who is living with a foster family but remains the legal
responsibility of a welfare or other agency shall be income eligible for
services.
•
An adopted child is counted in the household size of the family with whom
s/he resides.
•
A child family member who resides in a school or institution is counted as a
member of the household if the participant’s family pays for the child’s
support.
•
A pregnant woman should be counted as two, taking into consideration the
unborn fetus. If there is more than one fetus, the household size can be
increased by the number of expected births.
•
A pregnant unmarried teen (under 18 years of age) or an unmarried teen
(under 18 years of age) with a child or children can be counted as a separate
household.
•
In determining household size, a child must be under the age of 18, or be 18 or
19 and enrolled full time in a secondary school. If the child is 18 or 19, school
verification of full time enrollment in a secondary school must be attained.
Income Determination
•
Local agencies may establish their own policy of what to do when an
applicant does not have the necessary income information at the initial home
visit.
•
Income information is required except in extenuating circumstances where
this requirement would pose an unreasonable barrier to participation.
Examples of extenuating circumstances would be:
o Homeless woman or family
o Instances where there is domestic abuse
o Natural disasters
•
When calculating income, the adjusted gross income of the family during the
last twelve months, the month prior to application or their current income rate
may be used, whichever reflects the family’s status most accurately. However,
a local agency must apply the same method consistently for each applicant of
the same type of case (e.g., all persons who are seasonal workers or all
persons who are on strike). For self-employed persons whose income
fluctuates, persons on extended or maternity leave and students, and seasonal
workers who do not work 12 months of the year or are laid off and rehired,
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Appendix: TANF Grant Guidelines
eligibility must be determined based on adjusted gross annual income. If they
are not rehired as expected, their eligibility should be redetermined at that
time. If an individual receives child support on an infrequent or inconsistent
basis, an annual income determination might be more appropriate.
Income includes all of the following:
•
•
•
•
•
•
•
•
•
•
•
•
Monetary compensation for services, including wages, salary, commissions, or fees
Adjusted gross income from farm and non-farm self-employment (use the most
current income tax statement)
Social Security benefits
Dividends or interest on savings or bonds, income from estates or trusts, or net
rental
Public assistance or welfare payments
Unemployment compensation
Government civilian employee or military retirement or pensions or veteran’s
payment
Private pensions or annuities
Alimony or child support payments
Regular contributions from person not living in the household
Net royalties
Other cash income. This includes, but is not limited to, cash amount received or
withdrawn from any source, including savings investments, trust accounts and other
resources which are readily available to the family.
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Do NOT include the following as income:
•
•
•
•
•
•
•
•
The value of in-kind housing and other in-kind benefits. An in-kind benefit is anything of
value which is not provided in the form of cash
The value of assistance to children or their families under the national School Lunch Act, the
Child Nutrition Act of 1966, and the Food Stamp Act of 1977
The value of child care provided or arranged, or payments received under Child Care and
Development Block Grants
Payments or allowances received pursuant to the Home Energy Assistance Act of 1980
Payments received under the Job Training Partnership Act
Financial assistance received by an individual from any program funded under Title IV of the
Higher Education Act of 1965 (including the Pell Grant, Supplemental Educational
Opportunity Grant, State Student Incentive Grant, National Direct Student Loan, PLUS,
College Work Study, and Byrd Honor Scholarship programs), which is used by the student for
specified costs (such as books, equipment, materials, tuition, fees, supplies, and
transportation)
Any cash housing allowances received by military personnel living in off-base housing
Infrequent and irregular income, such as cash birthday gifts.
Determination of citizenship or eligible non-citizens
as defined under the Personal Responsibility and Work Opportunity Reconciliation Act of 1966, Public
Law 104-193 Determination.
•
All members of a household receiving family home visiting or WIC services must be
citizens of the United States or eligible non-citizens. Verbal declaration of citizenship
of all household members by parent or guardian must be recorded in the participant’s
chart. If a participant responds that all household members are citizens and the
household meets all other eligibility criteria, TANF funded family home visiting or
WIC services can be provided.
•
If a family home visiting or WIC participant who receives MFIP indicates that any
member of the household is a non-citizen, the local county human services agency
should be contacted to verify the funding source that is used to pay for the MFIP
grant. If the funding source is federally funded MFIP, the eligible non-citizen criteria
is met and family home visiting or WIC services can be provided. If the funding
source for the MFIP grant is state funds additional determination of eligibility based
on eligible non-citizen status should be completed. Use the checklist in Appendix A
to determine status.
•
If a family home visiting or WIC participant who does not receive MFIP indicates
that any member of the household is a non-citizen use the checklist in Appendix A to
determine if the family home visiting or WIC participant is an eligible non-citizen
and thus, eligible for TANF funded services.
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Appendix: TANF Grant Guidelines
•
When providing youth development services, effort should be made to provide
outreach for group activities to communities that are citizens or eligible non-citizens.
It is not necessary to determine or document the citizenship status of each individual
in the group.
Documentation of :
Household Size and Composition, Income and Citizenship Status for Family Home Visiting and WIC
Services.
Local agencies must keep at a minimum the following information in the
participant’s chart. The documentation may be kept in a format that meets the
agency’s needs.
Is the family receiving federally funded MFIP? (YES/NO)
If family is not receiving federally funded MFIP the following information must
be documented on the participant’s chart:
Are all members of the household US citizens/eligible non-citizens? (YES/NO)
Is annual household income at or below 200% of federal poverty
guidelines? (YES/NO)
Household includes (indicate all that apply):
_____ A pregnant women (age 20 or over)
_____ Child under age 18
_____ Child 18 and 19 who attends a secondary school full time (school
verification required)
_____ An adolescent (19 and under) who is pregnant or parenting
Matching Requirement
No match is required.
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Appendix: TANF Grant Guidelines
Program and Administrative Costs
Program Costs
Includes expenditures made to implement or support program activities.
Expenditures can include salary and fringe benefits for staff directly
involved in program activities. It also can include actual costs of such things
such as training materials, conference registration, mileage, outreach
activities, educational and safety materials for families, program planning,
evaluation or purchase of a computer.
The following CANNOT be reimbursed: patient medical care, family
planning medical services, capital improvements or alterations, cash
assistance paid directly to clients, childcare or client transportation, or any
cost not directly related to the grant.
Administrative Costs
Costs that represent the expenses of doing business that are not easily
identified with the program but are necessary for the general operation of
the organization and the conduct of activities it performs. Examples of such
expenses include accounting, human resources, general agency
administration, and costs to operate and maintain facilities.
Administrative costs can be computed as an indirect cost rate or through a
cost allocation plan. Administrative costs cannot exceed 15 percent of the
invoiced program costs or agency’s standard cost whichever is lower.
Administrative costs can only be incurred on expenditures.
Reporting Requirements
Invoices
Invoices are due on the 20th day of the month following the end of the
quarter.
October 20 for services provided July 1 through September 30
January 20 for services provided October 1 through December 31
April 20 for services provided January 1 through March 30
July 20 for services provided April 1 through June 30
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Appendix: TANF Grant Guidelines
Plan and Evaluation
Reporting requirements related to the Plan that must be submitted by local
public health departments and evaluation reports will be provided at a later
time after the Family Home Visiting Steering Committee and Evaluation
Work Group recommendations are received.
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