Family Home Visiting Unit
Maternal and Child Health Section
Community and Family Health Division
address: P.O. Box 64882, St. Paul, MN 55164
phone: 651-201-3760 | email: [email protected]
Family Home Visiting (FHV) Evaluation Benchmark Plan
I. Improved Maternal and Newborn Health
Benchmark
Construct
1-Prenatal care
(1.1)
2-Parental use of
tobacco (1.2)
Performance
Indicator
Average reported
weeks of pregnancy
at engagement in
home visiting
among women
enrolled prenatally 1
Percent of women
enrolled prenatally
who reported that
they smoked
cigarettes during
their pregnancy
Operational Definition
Process Indicator - Earlier engagement
in home visiting
Target population: All women enrolled
prenatally
Numerator: Sum of reported weeks of
pregnancy at engagement in home visiting
among women enrolled prenatally
Denominator: Total number of women
enrolled prenatally
Outcome Indicator - Reduction in
tobacco use among pregnant women
Target population: All women enrolled
prenatally
Numerator: Number of women enrolled
prenatally who reported that they smoked
cigarettes during their pregnancy
Denominator: Total number of women
enrolled prenatally who reported that they
smoked or did not smoke during their
pregnancy (excluding unknowns and
refusals)
Question or Measurement
Tool
Question:
How many weeks pregnant
are you (client) now?
Question:
Did you (client) smoke
cigarettes at all during your
pregnancy, including before
you found out you were
pregnant?
NFP:
Health Habits 2 (#2)
web: http://www.health.state.mn.us/fhv/index.cfm
Definition of Improvement
Data Collection Plan
Decrease in average reported
weeks of pregnancy at
engagement in home visiting
among women enrolled
prenatally; Years 1 & 2 cohort
comparisons
Data collected by:
Home visitor
Decrease in percent of
women enrolled prenatally
who reported that they
smoked cigarettes during
their pregnancy; Years 1 & 2
cohort comparisons
Data collected by:
Home visitor
Data source:
Client self-report
Frequency of data
collection:
Intake
Data source:
Client self-report
Frequency of data
collection:
1st postpartum visit
1 Justification
2
for the use of this measure: Current research indicates that enrollment in home visiting programs earlier in pregnancy enhances positive outcomes, including receipt of prenatal care.
The Health Habits form for NFP is completed at several intervals. The form that is completed at 36 weeks of pregnancy corresponds to data collection at the 1st postpartum visit.
Minnesota Department of Health
06112015 page 1
Benchmark
Construct
3-Preconception
care (1.3)
4-Inter-birth
intervals (1.4)
3
Performance
Indicator
Percent of
postpartum women
who reported that
they currently take
a vitamin containing
folic acid
Percent of
postpartum women
who reported that
they have not been
pregnant since the
birth of their last
(index) child
Operational Definition
Outcome Indicator - Improvement in
folic acid intake among postpartum
women
Target population: All postpartum women
enrolled
Numerator: Number of postpartum women
who reported that they currently take a
vitamin containing folic acid
Denominator: Total number of postpartum
women who reported that they currently
do or do not take a vitamin containing folic
acid (excluding unknowns and refusals)
Outcome Indicator - Expansion of interbirth intervals
Target population: All postpartum women
enrolled
Numerator: Number of postpartum women
who reported that they have not been
pregnant since the birth of their last
(index) child
Denominator: Total number of postpartum
women who reported that they have or
have not been pregnant since the birth of
their last child (excluding unknowns and
refusals)
Question or Measurement
Tool
Question:
Are you (client) currently
taking a vitamin containing
folic acid?
Question:
Since you had your infant,
have you (client) been
pregnant again?
NFP:
Demographics Update (#21)
Healthy People 2020 Objective (FP-5): Reduce the proportion of pregnancies conceived within 18 months of a previous birth.
Minnesota Department of Health
Definition of Improvement
Data Collection Plan
Increase in percent of
postpartum women who
reported that they currently
take a vitamin containing
folic acid at 6 months
postpartum; Years 1 & 2
cohort comparisons
Data collected by:
Home visitor
Increase in percent of
postpartum women who
reported that they have not
been pregnant since the birth
of their last (index) child at
12 months postpartum; Years
1 & 2 cohort comparisons
Data collected by:
Home visitor
Data source:
Client self-report
Frequency of data
collection:
6 months postpartum
Data source:
Client self-report
Frequency of data
collection:
12 & 18 months
postpartum 3
06112015 2
Benchmark
Construct
5-Screening for
maternal depressive
symptoms (1.5)
Performance
Indicator
Percent of
postpartum women
who were screened
for postpartum
depressive
symptoms
Operational Definition
Process Indicator - Improvement in
screening for depressive symptoms
Target population: All postpartum women
enrolled
Numerator: Number of postpartum women
who were screened with the EPDS or PHQ9 for postpartum depressive symptoms at
least once between the birth of their infant
and 3 months postpartum
Denominator: Total number of postpartum
women
Question or Measurement
Tool
EPDS or PHQ-9
psychometric measures
Question:
Was the mother screened with
a standardized instrument for
possible postpartum
depression at least once
between the birth of their
infant and 3 months
postpartum?
NFP:
(Calculated variable)
Edinburgh Postnatal
Depression Scale (EPDS) or
Patient Health Questionnaire9 (PHQ-9) 4
Definition of Improvement
Increase/maintain percent of
postpartum women screened
for postpartum depressive
symptoms at least once
between the birth of their
infant and 3 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection Plan
Data collected by:
Home visitor
Data source:
Home visitor charting
record
Frequency of data
collection:
Varies - 1st postpartum
visit; 1-8 weeks
postpartum (NFP); 3
months (HFA) 5
4 The EPDS and PHQ-9 forms for NFP are completed at several intervals, including 36 weeks of pregnancy, 1-8 weeks postpartum, and 4-6 months postpartum. The form that is completed at 36 weeks of pregnancy
corresponds to data collection at the 1st postpartum visit.
5 The screen for postpartum depression should be completed by 3 months postpartum; however, the data can be collected at the standard 6 months postpartum time interval.
Minnesota Department of Health
06112015 3
Benchmark
Construct
6-Breastfeeding
(1.6)
7. Well-child visits
(1.7)
Performance
Indicator
Average reported
number of weeks
that infants who
ever had breast milk
continued receiving
breast milk
Percent of
infants/children for
whom the
completion of at
least 50% of wellchild visits was
reported
Operational Definition
Outcome Indicator - Promotion of
continued breast milk for infants
Target population: All infants enrolled who
were breastfed
Numerator: Reported number of weeks of
continued breast milk consumption among
infants for whom past breast milk
consumption was reported (excluding
unknowns and refusals)
Denominator: Total number of infants for
whom past breast milk consumption was
reported (excluding unknowns and
refusals)
Outcome Indicator-
Improvement in well-child program
participation
Target population: All infants/children
enrolled
Numerator: Number of infants/children for
whom the completion of at least 50% of
recommended well-child care visits was
reported
Denominator: Total number of
infants/children for whom any proportion
of recommended well-child care visits was
reported (excluding unknowns and
refusals)
Question or Measurement
Tool
Question:
Definition of Improvement
Increase in average reported
number of weeks of
Has your infant ever had
continued breast milk
breast milk?
consumption at 6 months
postpartum among infants
Does your infant continue to
for whom past breast milk
get breast milk?
consumption was reported 6;
Years 1 & 2 cohort
How many weeks old was your
comparisons
infant when he or she stopped
getting breast milk?
NFP:
Infant Health Care (#12, 13,
14)
Question:
Has your child had 50% of
their well-child checkups? 7
NFP:
(Calculated variable)
Infant Health Care (#1)
Increase in percent of
infants/children for whom
the completion of at least
50% of well-child visits was
reported at 12 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection Plan
Data collected by:
Home visitor
Data source:
Client self-report
Frequency of data
collection:
6 & 12 months
postpartum
Data collected by:
Home visitor
Data source:
Client self-report
Frequency of data
collection:
12 & 24 months
postpartum
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding through 6 months of age. While this construct does not measure exclusive versus non-exclusive breastfeeding, it does measure the
continuation of breastfeeding over a similar follow-up period.
7 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), the
Early and Periodic Screening, Diagnosis & Treatment Schedule of Age-Related Screening Standards.
6
Minnesota Department of Health
06112015 4
Benchmark
Construct
8. Maternal and
child health
insurance status
(1.8)
Performance
Indicator
Percent of motherchild dyads for
whom some kind of
health insurance
coverage was
reported
Minnesota Department of Health
Operational Definition
Outcome Indicator Insurance coverage status
Target population: All postpartum women
& infants/children enrolled
Numerator: Number of mother-child dyads
for whom some kind of health insurance
coverage was reported, including private,
public, and military plans
Denominator: Total number of motherchild dyads for whom health insurance
coverage or non-coverage was reported
(excluding unknowns and refusals)
Question or Measurement
Tool
Question:
Do you (client) have health
insurance? If yes, what is your
major medical care resource
for health insurance?
Does your infant have health
insurance? If yes, what is your
infant’s major medical care
resource for health insurance?
NFP:
(Calculated variable)
Definition of Improvement
Increase in percent of
mother-child dyads for whom
some kind of health
insurance coverage was
reported at 6 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection Plan
Data collected by:
Home visitor
Data source:
Client self-report
Frequency of data
collection:
1st postpartum visit; 6,
12, 18, & 24 postpartum
Use of Government &
Community Services (Receipt
of service for #13-16
insurance plans)
06112015 5
II. Child Injuries, Abuse, Neglect or Maltreatment and Reduction of Emergency Department Visits
Benchmark Construct
Performance Indicator
9-Visits of infants/children
to the emergency
department from all causes
(2.1)
Percent of infants/children
for whom one or more visits
to the emergency
department or urgent care
center was reported
10-Visits of pregnant &
postpartum women to the
emergency department
from all causes (2.2)
Percent of pregnant &
postpartum women who
reported that they had
visit(s) to the emergency
department or urgent care
center
Minnesota Department of Health
Operational Definition
Outcome Indicator – Emergency
room visits of infants/children
Target population: All
infants/children enrolled
Numerator: Number of
infants/children for whom one or
more visits to the emergency
department or urgent care center was
reported
Denominator: Total number of
infants/children for whom any
number of visits to the emergency
department or urgent care center was
reported, including none (excluding
unknowns and refusals)
Outcome Indicator – Emergency
room visits pregnant & postpartum
women
Target population: All pregnant &
postpartum women enrolled
Numerator: Number of pregnant &
postpartum women who reported
that they had one or more visit(s) to
the emergency department or urgent
care center
Denominator: Total number of
pregnant and postpartum women
enrolled who reported any number of
visits to the emergency department
or urgent care center, including none
(excluding unknowns and refusals)
Question or Measurement
Tool
Question:
In the past 6 months, have
you taken your child to the
hospital emergency
room/urgent care center?
NFP:
Infant Health Care (#9,
#10)
Question:
[In the past 6 months/since
enrollment], have you
(client) obtained care at the
hospital emergency
room/urgent care center for
ANY reason?
NFP:
Demographics Pregnancy
Intake (#16-17); Infant
Birth (#9, 10);
Demographics Update (#23,
24)
Definition of
Improvement
Decrease in percent of
infants/children for whom
one or more visits to the
emergency department or
urgent care center was
reported by 12 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Decrease in percent of
pregnant & postpartum
women who reported that
they had visit(s) to the
emergency department or
urgent care center by 12
months postpartum; Years
1 & 2 cohort comparisons
Data collected
by:
Home visitor
Data source:
Client self-report
Frequency of
data collection:
6, 12, 18, & 24
months
postpartum
Data source:
Client self-report
Frequency of
data collection:
Intake; 1st
postpartum visit;
6, 12, 18, 24
months
postpartum
06112015 page 6
8
Benchmark Construct
Performance Indicator
11-Information provided or
training of pregnant &
postpartum women, and
other caregivers, on
prevention of child injuries
(2.3)
Percent of primary
caregivers who completed a
Home Safety Checklist or
equivalent
12-Incidence of infant/child
injuries requiring medical
treatment (2.4)
Percent of infants/children
for whom one or more visits
to the emergency
department or urgent care
center for an injury was
reported
Operational Definition
Process Indicator - Completion of
home safety checklist
Target population: All primary
caregivers enrolled
Numerator: Number of primary
caregivers who completed a Home
Safety Checklist or equivalent
Denominator: Total number of
primary caregivers
Outcome Indicator – Infant/child
injuries requiring medical
treatment
Target population: All
infants/children enrolled
Numerator: Number of
infants/children for whom one or
more visit(s) to the emergency
department or urgent care center for
an injury was reported
Denominator: Total number of
infants/children for whom any
number of visits to the emergency
department or urgent care center for
an injury was reported, including
none (excluding unknowns and
refusals)
Question or Measurement
Tool
Question:
Does this client have a Home
Safety Checklist 8 (or
equivalent) completed?
NFP:
Home Visit Encounter (#1)
Question:
In the past 6 months, have
you taken your child to the
hospital emergency
room/urgent care center for
an injury?
NFP:
Infant Health Care (#9)
The Home Safety Checklist (Minnesota Department of Health) is available online at: http://www.health.state.mn.us/divs/fh/mch/fhv/safety.html.
Minnesota Department of Health
Definition of
Improvement
Increase/maintain percent
of primary caregivers
enrolled who completed a
Home Safety Checklist or
equivalent by 6 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Decrease in percent of
infants/children for whom
one or more visits to the
emergency department or
urgent care center for an
injury was reported by 6
months postpartum; Years
1 & 2 cohort comparisons
Data collected
by:
Home visitor
Data source:
Home visitor
charting records
Frequency of
data collection:
1st postpartum
visit; 6 months
postpartum
Data source:
Client self-report
Frequency of
data collection:
6, 12, 18, & 24
months
postpartum
06112015 7
Benchmark Construct
Performance Indicator
13-Reported suspected
maltreatment among
infants/children - reports:
i.e., allegations, not
substantiated/ determined
(2.5)
Percent of infants/ children
for whom reports were
made to the Child
Protection Agency for
suspected maltreatment
Minnesota Department of Health
Operational Definition
Outcome Indicator – Reports of
infant/child maltreatment
Target population: All
infants/children enrolled
Numerator: Infants/children for
whom reports were made to the Child
Protection Agency for suspected child
maltreatment
Denominator: Total number of
infants/children
Question or Measurement
Tool
Question:
Is there currently an active
file at the lead CPA of
suspected maltreatment for
this infant/child?
Definition of
Improvement
Decrease in percent of all
instances of reported
suspected maltreatment
among infants/children at 6
months postpartum; Years
1 & 2 cohort comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Administrative
data from the
agency’s lead
Child Protection
Agency
Frequency of
data collection:
6 & 12 months
postpartum
06112015 8
Benchmark Construct
14-Substantiated
maltreatment cases among
infants/children (2.6)
Performance Indicator
Operational Definition
Percent of infants/children
with substantiated child
maltreatment cases
Outcome Indicator – Substantiated
infant and child maltreatment
Target population: Infants/children
enrolled for whom reports were
made to the Child Protection Agency
for suspected child maltreatment
Numerator: Infants/children with a
maltreatment report as substantiated
by the lead Child Protection Agency
Denominator: Total number of
infants/children for whom reports
were made to the Child Protection
Agency for suspected child
maltreatment
Question or Measurement
Tool
Question:
Was the suspected case of
maltreatment substantiated
by the lead CPA?
Definition of
Improvement
Decrease in percent of
infants/children with
substantiated child
maltreatment at 6 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection
Plan
Data collected
by:
Home
visitor/other
agency-appointed
data staff
Data source:
Administrative
data from the
agency’s lead
Child Protection
Agency
Frequency of
data collection:
6 & 12 months
postpartum
Minnesota Department of Health
06112015 9
Benchmark Construct
15-First-time victims of
maltreatment among
infants/children (2.7)
9
Performance Indicator
Percent of infants/children
with substantiated child
maltreatment who are firsttime victims of
maltreatment
Operational Definition
Outcome Indicator - First-time
victims of child maltreatment 9
Target population: Infants/children
with a maltreatment report as
substantiated by the lead Child
Protection Agency
Numerator: Number of
infants/children who are first-time
victims of maltreatment
Denominator: Total number of
infants/children with a maltreatment
report as substantiated by the lead
Child Protection Agency
Question or Measurement
Tool
Question:
Was the infant/child of the
substantiated case of
maltreatment a first-time
victim, as reported by lead
CPA?
Definition of
Improvement
Decrease in percent of
infants/children with
substantiated child
maltreatment who are firsttime victims at 6 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection
Plan
Data collected
by:
Home
visitor/other
agency-appointed
data staff
Data source:
Administrative
data from the
agency’s lead
Child Protection
Agency
Frequency of
data collection:
6 & 12 months
postpartum
According to the Home Visiting Updated State Plan – OMB Control Num. 0915-00226, ‘first-time victim’ is defined as a child who had a maltreatment disposition of ‘victim’ and never had a prior disposition of victim.
Minnesota Department of Health
06112015 10
III. Improvements in School Readiness & Achievement
Benchmark Construct
16-Parent support for
children’s learning &
development - e.g., having
appropriate toys available,
talking and reading with
their child (3.1)
Performance Indicator
Operational Definition
Percent of parents with
improved support for their
child’s learning and
development, as measured
by higher overall NCAST
Teaching Sub-Scale Scores
III & IV (HFA)
Outcome Indicator – Parent
support for infant/child learning &
development
OR the Dyadic Assessment
of Naturalistic CaregiverChild Experiences (DANCE)
Promotion of
Developmental Growth
(PDG) scale scores (NFP)
10
11
Target population: All parents
enrolled
Numerator: Number of parents with
improved overall NCAST PCI
Teaching Sub-Scale Scores III & IV
from time of first assessment to 12
months postpartum
Alternative Numerator: Number of
parents with improved overall
DANCE PDG scores from 2 months to
9 months postpartum
Denominator: Total number of
parents for whom an NCAST
assessment was completed
Alternative Denominator: Total
number of parents for whom DANCE
assessments were completed at 2 and
9 months postpartum
Question or Measurement
Tool
NCAST PCI Teaching
Subscale Scores 10 III &
IV: Social-Emotional
Growth Fostering &
Cognitive Growth Fostering
Dyadic Assessment of
Naturalistic Caregiver-Child
Experiences (DANCE)
Definition of
Improvement
Increase in percent of
parents with higher overall
NCAST PCI Teaching SubScale Scores III & IV from
time of first assessment to
12 months postpartum;
Individual comparisons
(HFA)
Increase in percent of
parents with improved
overall DANCE PDG scores
from 2 to 9 months
postpartum (NFP)
NCAST PCI Teaching Scale psychometric measures (Sumner, 1994): Split-half reliability coefficient = .87, Test-retest reliability coefficient = .85
The initial NCAST or HOME assessment should be completed by 3 months postpartum; however, the data can be collected at the standard 6 months postpartum time interval.
Minnesota Department of Health
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Home visitor
observation using
the NCAST PCI
Teaching (or
DANCE)
Assessment
Frequency of
data collection:
3 months
postpartum 11; 12
months
postpartum
(NCAST)
Or 2 months
postpartum; 9
months
postpartum
(DANCE)
06112015 page 11
Benchmark Construct
Performance Indicator
Operational Definition
17-Parent knowledge of
child development & of
their child’s developmental
progress (3.2)
Percent of parents with
increased knowledge of
child development and of
their child’s developmental
progress, as measured by
discussion of ASQ-3 and
ASQ:SE results with the
home visitor
Process Indicator – Parental
knowledge of child development &
developmental progress
Minnesota Department of Health
Target population: All parents
enrolled
Numerator: Number of parents
enrolled who discussed ASQ-3 and
ASQ:SE results with the home visitor
Denominator: Total number of
parents enrolled whose infants were
screened with the ASQ-3 and ASQ:SE
Question or Measurement
Tool
Question:
Has the home visitor
discussed the infant/child’s
ASQ-3 (10/12 month) with
the primary caregiver?
Has the home visitor
discussed the infant/child’s
ASQ:SE score (12 month)
with the primary caregiver?
Definition of
Improvement
Increase/maintain percent
of parents enrolled who
discussed their child’s ASQ3 results (10/12 months
scores) and ASQ:SE results
(12 month scores) with the
home visitor at 12 months
postpartum; Years 1 & 2
cohort comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Home visitor
charting records;
interview with
parent
Frequency of
data collection:
12 months
postpartum
06112015 12
Benchmark Construct
18-Parenting behaviors &
parent-child relationship e.g., discipline strategies,
play interactions (3.3)
12
13
Question or Measurement
Tool
Percent of parents with
Outcome Indicator – Improved
NCAST PCI Teaching
improved parent-child
parenting behaviors & parent-child Subscale Scores I, II, V,
relationships, as measured
relationship
VI: 12
by higher overall NCAST PCI
Sensitivity to Cues,
Target
population:
All
parents
Teaching Sub-Scale Scores I,
Response to Child’s
enrolled
II, V, & VI (HFA)
Distress, Clarity of Cues,
Numerator: Number of parents with
Responsiveness to
improved overall NCAST PCI
Caregiver (HFA)
Teaching Sub-Scale Scores I, II, V, VI
OR the Dyadic Assessment
from time of first assessment to 12
Dyadic Assessment of
of Naturalistic Caregivermonths postpartum
Naturalistic Caregiver-Child
Child Experiences (DANCE) Alternative Numerator: Number of
Experiences (DANCE)
Promotion of
parents with improved overall
(NFP)
Developmental Growth
DANCE scores from 2 months to 9
(PDG) scale scores (NFP)
months postpartumDenominator:
Total number of parents enrolled for
whom an NCAST assessment was
completed
Alternative Denominator:
Total number of parents for whom
DANCE assessments were completed
at 2 and 9 months postpartum
Performance Indicator
Operational Definition
Definition of
Improvement
Increase in percent of
parents with higher overall
NCAST PCI Teaching SubScale Scores I, II, V & VI
from time of first
assessment to 12 months
postpartum; Individual
comparisons
Increase in the percent of
parents with improved
overall DANCE PDG scores
from 2 months to 9 months
NCAST PCI Teaching Scale psychometric measures (Sumner, 1994): Split-half reliability coefficient = .87, Test-retest reliability coefficient = .85
The initial NCAST or HOME assessment should be completed by 3 months postpartum; however, the data can be collected at the standard 6 months postpartum time interval.
Minnesota Department of Health
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Home visitor
observation using
the NCAST PCI
Teaching
Assessment (or
DANCE)
Frequency of
data collection:
3 months
postpartum 13; 12
months
postpartum
(NCAST)
Or 2 months
postpartum;9
months
postpartum
(DANCE)
06112015 13
Benchmark Construct
19-Parent emotional wellbeing or parenting stress
(3.4)
Performance Indicator
Percent of parents screened
positive for postpartum
depression using the EPDS
or PHQ-9 who were
referred to relevant
community resources
Operational Definition
Outcome Indicator – Parental
emotional well-being, stress
Target population: Parents enrolled
who screened positive for
postpartum depressive symptoms
Numerator: Number of parents
screened positive for postpartum
depressive symptoms using the EPDS
or PHQ-9 at least once between the
birth of their infant and 3 months
postpartum who received a referral
for relevant community resources
Denominator: Total number of
parents screened positive for
postpartum depressive symptoms
using the EPDS or PHQ-9
Question or Measurement
Definition of
Tool
Improvement
EPDS 14 or PHQ-9 15
Increase/maintain percent
psychometric measures
of parents screened positive
for postpartum depression
Question:
using the EPDS or PHQ-9 at
Was the mother referred to
least once between the
relevant community
birth of their infant and 3
resources for screening
months postpartum who
positive for postpartum
were referred to relevant
depression?
community resources;
Years 1 & 2 cohort
NFP:
comparisons
(Calculated variable)
Edinburgh Postnatal
Depression Scale (EPDS) or
Patient Health
Questionnaire-9 (PHQ-9) 16;
Home Visit Encounter or
Alternative Encounter
(Referral for #8 Mental
health treatment or therapy
or #9 Relationship
counseling)
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
& Home Visitor
charting records
Frequency of
data collection:
Varies - 1st
postpartum visit;
1-8 weeks
postpartum
(NFP); 3 months
(HFA) 17
A cutoff score of 10 or greater on the EPDS is indicative of possible depression.
A score of 10 or greater on the PHQ-9 represents the cutoff for ‘moderate’ or more severe depression, indicating the need for a treatment plan, possible counseling or follow-up, and/or pharmacotherapy. Kroenke K,
Spitzer RL, Psychiatric Annals 2002;32:509-521.
16 The EPDS and PHQ-9 forms for NFP are completed at several intervals, including 36 weeks of pregnancy, 1-8 weeks postpartum, and 4-6 months postpartum. The form that is completed at 36 weeks of pregnancy
corresponds to data collection at the 1st postpartum visit.
17 The screen for postpartum depression should be completed by 3 months postpartum; however, the data can be collected at the standard 6 months postpartum time interval.
14
15
Minnesota Department of Health
06112015 14
Benchmark Construct
Performance Indicator
20-Infant/child
communication, language,
and emergent literacy (3.5)
Percent of infants meeting
developmental milestones
for communication, as
measured by scoring above
the referral cutoff score for
Communication on the ASQ3
Operational Definition
Outcome Indicator – Child
communication, language and
emergent literacy skills
Question or Measurement
Definition of
Tool
Improvement
ASQ-3 18
Increase in percent of
infants meeting
Question:
developmental milestones
Please indicate whether the
for communication, as
child’s ASQ-3 scores at [4
measured by scoring above
months, 10/12 months] of
the referral cutoff score for
age are below the
Communication on the ASQestablished referral score
3 at 4 months postpartum;
cutoff in the following areas: Years 2 & 3 cross-sectional
Communication 19
comparisons
Target population: All infants
enrolled
Numerator: Number of infants
screened with the ASQ-3 at 4 months
postpartum who scored above the
referral cutoff score for
Communication
Denominator: Total number of infants NFP:
enrolled who were screened with the (Calculated variable)
Infant Health Care (#16)
ASQ-3 at 4 months postpartum
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
using the ASQ-3
Frequency of
data collection:
4 months
postpartum (may
be collected on 6
month
postpartum
form); 10/12
months
postpartum
The Ages and Stages Questionnaire, Version 3 (ASQ-3) is a screening tool that assesses children’s development across 5 domains: communication, gross motor, fine motor, problem solving and person-social
development. Split-half reliability coefficient = .51-.85, Test-retest reliability coefficient= .92, Concurrent validity = .86, Sensitivity = 86%, Specificity = 86%
19 A response of “no” is included in the numerator. The ASQ-3 Communication referral cutoff score is 34.60 at 4 months of age; 22.87 at 10 months; 15.64 at 12 months.
18
Minnesota Department of Health
06112015 15
Benchmark Construct
21-Child’s general cognitive
skills (3.6)
Performance Indicator
Percent of infants meeting
developmental milestones
for cognition, as measured
by scoring above the
referral cutoff score for
Problem Solving on the
ASQ-3
Question or Measurement
Definition of
Tool
Improvement
Outcome Indicator – Child
ASQ-3 20
Increase in percent of
cognitive skills
infants meeting
Question:
developmental milestones
Target population: All infants
Please indicate whether the
for cognition, as measured
enrolled
child’s ASQ-3 scores at [4
by scoring above the
Numerator: Number of infants
months, 10/12 months] of
referral cutoff score for
screened with the ASQ-3 at 4 months age are below the
Problem Solving on the
established referral score
postpartum who scored above the
ASQ-3 at 4 months
referral cutoff score for Problem
cutoff in the following areas: postpartum; Years 2 & 3
Solving
Problem Solving 21
cross-sectional
Denominator: Total number of infants
comparisons
enrolled who were screened with the NFP:
(Calculated variable)
ASQ-3 at 4 months postpartum
Infant Health Care (#16)
Operational Definition
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
using the ASQ-3
Frequency of
data collection:
4 months
postpartum (may
be collected on 6
month
postpartum
form); 10/12
months
postpartum
The Ages and Stages Questionnaire, Version 3 (ASQ-3) is a screening tool that assesses children’s development across 5 domains: communication, gross motor, fine motor, problem solving and person-social
development. Split-half reliability coefficient = .51-.85, Test-retest reliability coefficient= .92, Concurrent validity = .86, Sensitivity = 86%, Specificity = 86%
21 A response of “no” is included in the numerator. The ASQ-3 Problem Solving referral cutoff score is 34.98 at 4 months of age; 32.51 at 10 months of age; 27.32 at 12 months of age.
20
Minnesota Department of Health
06112015 16
Benchmark Construct
22-Child’s positive
approaches to learning
including attention (3.7)
Performance Indicator
Percent of infants meeting
developmental milestones
for learning, as measured
by scoring above the
Personal-Social referral
cutoff score on the ASQ-3
Operational Definition
Outcome Indicator – Child
approach to learning including
attention
Question or Measurement
Definition of
Tool
Improvement
ASQ-3 22
Increase in percent of
infants meeting
Question:
developmental milestones
Please indicate whether the
for cognition, as measured
child’s ASQ-3 scores at [4
by scoring above the
months, 10/12 months] of
Personal-Social referral
age are below the
cutoff score on the ASQ-3 at
established referral score
4 months of postpartum;
cutoff in the following areas: Years 2 & 3 cross-sectional
Personal-Social 23
comparisons
Target population: All infants
enrolled
Numerator: Number of infants
screened with the ASQ-3 at 4 months
postpartum who scored above the
Personal-Social referral cutoff score
Denominator: Total number of infants
enrolled who were screened with the NFP:
(Calculated variable)
ASQ-3 at 4 months postpartum
Infant Health Care (#16)
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
using the ASQ-3
Frequency of
data collection:
4 months
postpartum (may
be collected on 6
month
postpartum
form); 10/12
months
postpartum
22 The Ages and Stages Questionnaire, Version 3 (ASQ-3) is a screening tool that assesses children’s development across 5 domains: communication, gross motor, fine motor, problem solving and person-social
development. Split-half reliability coefficient = .51-.85, Test-retest reliability coefficient= .92, Concurrent validity = .86, Sensitivity = 86%, Specificity = 86%
23 A response of “no” is included in the numerator. The ASQ-3 Personal-Social referral cutoff score is 33.16 at 4 months of age; 27.27 at 10 months; 21.73 at 12 months.
Minnesota Department of Health
06112015 17
Benchmark Construct
23-Child’s social behavior,
emotion regulations, and
emotional well-being (3.8)
24-Child’s physical health &
development (3.9)
Performance Indicator
Percent of infants meeting
social-emotional
milestones, as measured by
scoring below the referral
cutoff score on the ASQ:SE
Percent of infants/children
who did not meet the
classification for
“underweight” or “obese”
using WHO weight-forlength growth charts
Operational Definition
Outcome Indicator – Child social,
behavior, emotion regulations &
emotional well-being
Question or Measurement
Definition of
Tool
Improvement
ASQ:SE 24 psychometric
Increase in percent of
measures
infants meeting socialemotional milestones, as
Question:
measured by scoring below
Please indicate whether the
the referral cutoff score on
child’s ASQ:SE scores at 12
the ASQ:SE at 12 months
months of age are above the postpartum; Years 2 & 3
established referral cutoff
cross-sectional
score. 25
comparisons
Data Collection
Plan
Data collected
by:
Question:
What is the child’s current
weight?
Data collected
by:
Home visitor
Target population: All infants
enrolled
Numerator: Number of infants
screened at with the ASQ:SE at 12
months postpartum who scored
below the referral cutoff score
Denominator: Total number of infants NFP:
(Calculated variable)
enrolled who were screened at with
the ASQ:SE at 12 months postpartum Infant Health Care (#16)
Outcome Indicator - Child’s
physical health & development
Target population: All
infants/children enrolled
Numerator: Number of
infants/children who did not meet
the classification for “underweight” or
“obese” using WHO weight-for-length
growth charts
Denominator: Total number of
infants/children enrolled for whom
weight and length were reported or
recorded (excluding unknowns)
What is the child’s current
length? (measure head-totoe)
NFP:
Infant Health Care (#6, #7)
Increase in percent of
infants/children who did
not meet the classification
for “underweight” or
“obese” using WHO weightfor-length growth charts 26
at 12 months postpartum;
Years 2 & 3 cross-sectional
comparisons
Home visitor
Data source:
Client self-report
using the ASQ:SE
Frequency of
data collection:
12 months
postpartum
Data source:
Client self-report
or Home visitor
charting records
Frequency of
data collection:
6, 12, 18, & 24
months
postpartum
Social-Emotional psychometric measures Sub-scale Personal, social Internal consistency reliability coefficient = .82, Test-retest reliability coefficient = .94, Squires, J., Bricker, D., Twombly, E., Yockelson, S., & Kim, Y.
(1996). Behavior-Ages & Stages Questionnaires. Eugene: University of Oregon, Center on Human Development.
25 A response of “no” would be included in the numerator. The ASQ:SE referral cutoff score is 48 at 12 months of age.
26 In 2006, an expert panel convened by the CDC, the National Institutes of Health, and the American Academy of Pediatrics recommended the use of the 2006 WHO international growth standard for the assessment of
growth among all children aged <24 months, regardless of type of feeding. Centers for Disease Control and Prevention. Use of World Health Organization and CDC Growth Charts for Children Aged 0-59 Months in the
United States. MMWR 2010;59(No. RR-9):9-10. The growth charts are available online at: http://www.cdc.gov/growthcharts. Values of 2 standard deviations above and below the median, or the 2.3rd and 97.7th
percentiles (not the 5th and 95th percentiles) are recommended to screen for possible abnormal or unhealthy growth.
24
Minnesota Department of Health
06112015 18
IV. Domestic Violence
Benchmark Construct
25-Screening for domestic
violence (4.1)
Performance Indicator
Percent of prenatal and
postpartum women
enrolled who were
screened
for domestic violence using
a standardized tool
Operational Definition
Process Indicator – Screening for
domestic violence
Target population: All prenatal and
postpartum women enrolled
Numerator: Number of prenatal and
postpartum women who were
screened for domestic violence using
the NFP Relationship Assessment or
HFA HARK-C Survey
Denominator: Total number of
prenatal and postpartum women
Question or Measurement
Definition of
Tool
Improvement
NFP Relationship
Increase/maintain percent
Assessment
of prenatal and postpartum
women who were screened
HFA Humiliation Afraid
for domestic violence using
Rape Kick Child (HARK-C) the NFP Relationship
Survey
Assessment or HFA HARK-C
Survey by 3 months
Question:
postpartum 28; Years 1 & 2
Was the client screened for
cohort comparisons
the presence of domestic
violence using the NFP
Relationship Assessment or
HFA Humiliation Afraid
Rape Kick Child Survey
(HARK-C)?
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Home visitor
charts
Frequency of
data collection:
6 months
postpartum 29
NFP:
(Calculated variable)
Relationship Assessment 27
27 The Relationship Assessment form for NFP is completed at several intervals, including ‘Pregnancy 36 Weeks’ and ‘Infancy 12 Months’. The ‘Pregnancy 36 Weeks’ form corresponds to data collection at the 1st
postpartum visit.
28 Includes any screen completed by 6 months postpartum, including the prenatal period
29 The screen for domestic violence should be completed by 3 months postpartum; however, the data can be collected at the standard 6 months postpartum time interval.
Minnesota Department of Health
06112015 page 19
Benchmark Construct
Performance Indicator
26-Of postpartum women
identified for the presence
of domestic violence,
number of referrals made to
relevant domestic violence
services (4.2)
Percent of prenatal and
postpartum women
identified for the presence
of domestic violence using a
standardized screening tool
who received a referral to
relevant domestic violence
services
Operational Definition
Process Indicator – Referrals of
prenatal, and postpartum women,
screening positive for domestic
violence
Target population: All prenatal and
postpartum women enrolled
Numerator: Number of prenatal and
postpartum women identified for the
presence of domestic violence using
the NFP Relationship Assessment or
HFA HARK-C Survey who received a
referral to relevant domestic violence
services
Denominator: Total number of
prenatal and postpartum women
identified for the presence of
domestic violence using the NFP
Relationship Assessment or HFA
HARK-C Survey
Question or Measurement
Definition of
Tool
Improvement
NFP Relationship
Increase/maintain percent
Assessment 30
of prenatal and postpartum
women identified for the
HFA Humiliation Afraid
presence of domestic
Rape Kick Child (HARK-C) violence using the NFP
Survey 31
Relationship Assessment or
HFA HARK-C Survey by 3
Question:
months postpartum who
Did the screening tool reveal received a referral to
evidence of domestic
relevant domestic violence
violence?
services; Years 1 & 2 cohort
comparisons
If yes, was a referral made to
relevant domestic violence
services and noted in the
client’s chart?
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Home visitor
charts
Frequency of
data collection:
6 months
postpartum 33
NFP:
(Calculated variable)
Relationship Assessment 32;
Home Visit Encounter or
Alternative Encounter
(Referral for #6 Intimate
Partner Violence or #7
Child Protective Services)
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 (note: question 13 does not occur on all NFP Relationship Assessment forms).
Receipt of referral services for Intimate Partner Violence (#6) or Relationship Counseling (#9) on the Home Visit Encounter forms will be used as criteria for referral to relevant domestic violence services.
31 A cutoff score of 1 will be used as criteria for a positive screen. Source: Sohal, et al. BMC Family Practice 2007 8:49, The sensitivity of the optimal HARK cut-off score of ≥1 was 81% (95% C.I. 69% to 90%), specificity
95% (95% C.I. 91% to 98%), positive predictive value 83% (95% C.I. 70% to 91%), negative predictive value 94% (95% C.I. 90% to 97%), likelihood ratio 16 (95% C.I. 8 to 31) and post-test odds 5.
32 The Relationship Assessment form for NFP is completed at several intervals, including ‘Pregnancy 36 Weeks’ and ‘Infancy 12 Months’. The ‘Pregnancy 36 Weeks’ form corresponds to data collection at the 1st
postpartum visit.
33 The screen for domestic violence should be completed by 3 months postpartum; however, the data can be collected at the standard 6 months postpartum time interval.
30
Minnesota Department of Health
06112015 20
Benchmark Construct
27-Of postpartum women
identified for the presence
of domestic violence,
number of families for
which a verbal or written
safety plan was completed
(4.3)
Performance Indicator
Percent of prenatal and
postpartum women
identified for the presence
of domestic violence using a
standardized screening tool
who completed an Intimate
Partner Violence Safety
Plan or equivalent
Operational Definition
Process Indicator –Completion of
safety plans for domestic violence
Target population: All postpartum
women enrolled
Numerator: Number of prenatal and
postpartum women identified for the
presence of domestic violence using
the NFP Relationship Assessment or
HFA HARK-C Survey who completed
an Intimate Partner Violence Safety
Plan or equivalent
Denominator: Total number of
prenatal and postpartum women
identified for the presence of
domestic violence using the NFP
Relationship Assessment or HFA
HARK-C Survey
Question or Measurement
Tool
Question:
Was an Intimate Partner
Violence Safety plan
discussed, completed or
reviewed today?
NFP:
(Calculated variable)
Relationship Assessment 34;
Home Visit Encounter (#2)
Definition of
Improvement
Increase/maintain percent
of prenatal and postpartum
women identified for the
presence of domestic
violence using the NFP
Relationship Assessment or
HFA HARK-C Survey by 3
months postpartum who
completed an Intimate
Partner Violence Safety
Plan or equivalent; Years 1
& 2 cohort comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Home visitor
charting records
Frequency of
data collection:
6 months
postpartum 35
34 The Relationship Assessment form for NFP is completed at several intervals, including ‘Pregnancy 36 Weeks’ and ‘Infancy 12 Months’. The ‘Pregnancy 36 Weeks’ form corresponds to data collection at the 1st
postpartum visit.
35 The screen for domestic violence should be completed by 3 months postpartum; however, the data can be collected at the standard 6 months postpartum time interval.
Minnesota Department of Health
06112015 21
V. Family Economic Self-Sufficiency
Benchmark Construct
28-Household income &
benefits (5.1)
Question or Measurement
Tool
Increase in percent of
Outcome Indicator – Increased
Question:
primary caregivers who
annual earnings from work, plus
Which category best
reported a higher category
other sources of cash support,
describes your (client’s) total
of annual household income including private sources (e.g., rent annual household income
& benefits 36
from tenants/borders, cash
and benefits?
assistance from friends/relatives)
NFP:
or public sources (e.g., child
Demographics Pregnancy
support payments, TANF, Social
Intake (#13); Demographics
Security - SSI/SSDI/OAI, and
Update (#15)
unemployment insurance)
Performance Indicator
Operational Definition
Target population: All primary
caregivers enrolled
Numerator: Total number of primary
caregivers who reported a higher
category of annual household income
& benefits from intake to 12 months
post-enrollment
Denominator: Total number of
primary caregivers enrolled who
reported their annual household
income & benefits at intake and 12
months post-enrollment (excluding
unknowns and refusals)
Definition of
Improvement
Increase in percent of
primary caregivers who
reported a higher category
of annual household income
& benefits from intake to 12
months post-enrollment 37;
Years 1 & 2 cohort
comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
Frequency of
data collection:
Intake; 6, 12, 18, &
24 months
postpartum
36 Income determining poverty status must include the income of all of those living in the home who stay there at least 4 nights a week on average and contribute to the support of the child or pregnant woman linked to
the program. Tenants/boarders shall not be counted as members of the household
37 Follow-up will be measured at the first available 6-month postpartum interval after the client has attained at least 12 months of enrollment in a home visiting program
Minnesota Department of Health
06112015 page 22
Benchmark Construct
29-Education of adult
members of the household
(5.2)
38
39
Performance Indicator
Number of primary
caregivers who reported
that they completed one or
more educational programs
or classes
Operational Definition
Outcome Indicator – Improved
education/training of adult
household members
Target population: All primary
caregivers enrolled
Numerator: Number of primary
caregivers who reported that they
completed one or more educational
programs or classes in the past 12
months
Denominator: Total number of
primary caregivers enrolled who
reported that they did or did not
complete one or more educational
programs or classes in the past 12
months (excluding unknowns and
refusals)
Question or Measurement
Tool
Question:
[In the past 6 months/since
enrollment], have you
(client) completed any
educational programs or
classes, such as grade
advancement, certificate,
ESOL 38, etc.?
If yes, specify program.
Definition of
Improvement
Increase in percent of
primary caregivers who
reported that they
completed one or more
educational programs or
classes in the past 12
months at 12 months postenrollment 39; Years 1 & 2
cohort comparisons
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)
Follow-up will be measured at the first available 6-month postpartum interval after the client has attained at least 12 months of enrollment in a home visiting program
Minnesota Department of Health
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
Frequency of
data collection:
Intake; 1st
postpartum visit;
6, 12, 18, & 24
months
postpartum
06112015 23
Benchmark Construct
30-Insurance coverage of
pregnant women, mothers,
infants/children (5.3)
40
Performance Indicator
Percent of primary
caregivers and
infants/children for whom
some kind of health
insurance coverage was
reported
Operational Definition
Outcome Indicator Insurance coverage status
Target population: All primary
caregivers and infants/children
enrolled
Numerator: Number of primary
caregivers and infants/children for
whom some kind of health insurance
coverage was reported, including
private, public, and military plans
Denominator: Total number of
primary caregivers and
infants/children for whom health
insurance coverage or non-coverage
was reported (excluding unknowns
and refusals)
Question or Measurement
Tool
Question:
Do you (client) have health
insurance? If yes, what is
your major medical care
resource for health
insurance?
Does your infant have health
insurance? If yes, what is
your infant’s major medical
care resource for health
insurance?
Definition of
Improvement
Increase in percent of
primary caregivers and
infants/children for whom
some kind of health
insurance coverage was
reported at 12 months postenrollment 40; Years 1 & 2
cohort comparisons
NFP:
(Calculated variable)
Use of Government &
Community Services
(Receipt of service for #1316 insurance plans)
Follow-up will be measured at the first available 6-month postpartum interval after the client or infant/child has attained at least 12 months of enrollment in a home visiting program
Minnesota Department of Health
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
Frequency of
data collection:
Intake (primary
caregivers only);
1st postpartum
visit; 6, 12, 18, &
24 postpartum
06112015 24
VI. Coordination of Referral for Other Community Resources & Supports
Benchmark Construct
31-Number of families
identified for necessary
services (6.1)
Performance Indicator
Percent of infants identified
for possible developmental
or social-emotional delay
Operational Definition
Process Indicator - Improved
infant & child screening for
developmental &/or socialemotional milestones
Target population: All infants
enrolled
Numerator: Number of infants who
scored below the referral cutoff score
for any developmental milestone,
including the Communication, Gross
Motor, Fine Motor, Problem Solving,
or Personal-Social areas on the ASQ3 or who scored above the referral
cutoff score for social-emotional
milestones on the ASQ:SE
Denominator: Total number of infants
screened using the ASQ-3 and/or
ASQ:SE enrolled
Question or Measurement
Definition of
Tool
Improvement
ASQ-3 41 and ASQ:SE 42
Increase/maintain percent
of infants who scored below
Question:
the referral cutoff score for
Please indicate whether the
Communication, Gross
child’s ASQ-3 scores at [4
Motor, Fine Motor, Problem
months, 10/12 months] of
Solving, or Personal-Social
age are below the
on the ASQ-3 at 12 months
established referral score
postpartum or who scored
cutoff in the following areas: above the referral cutoff
Communication 43, Gross
score on the ASQ:SE at
Motor 44, Fine Motor 45,
10/12 months postpartum;
Problem Solving 46, Personal- Years 2 & 3 cross-sectional
Social 47
comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report
Frequency of
data collection:
10/12 months
postpartum
Please indicate whether the
child’s ASQ:SE scores at [12
months/24 months] of age
are above the established
referral cutoff score. 48
NFP:
(Calculated variable)
Infant Health Care (#16)
The Ages and Stages Questionnaire, Version 3 (ASQ-3) is a screening tool that assesses children’s development across 5 domains: communication, gross motor, fine motor, problem solving and person-social
development. Split-half reliability coefficient = .51-.85, Test-retest reliability coefficient= .92, Concurrent validity = .86, Sensitivity = 86%, Specificity = 86%
42 Social-Emotional psychometric measures Sub-scale Personal, social Internal consistency reliability coefficient = .82, Test-retest reliability coefficient = .94, Squires, J., Bricker, D., Twombly, E., Yockelson, S., & Kim, Y.
(1996). Behavior-Ages & Stages Questionnaires. Eugene: University of Oregon, Center on Human Development.
43 The ASQ-3 Communication referral cutoff score is 34.60 at 4 months of age; 22.87 at 10 months; 15.64 at 12 months.
44 The ASQ-3 Gross Motor referral cutoff score is 38.41 at 4 months of age; 30.07 at 10 months of age; 21.49 at 12 months of age.
45 The ASQ-3 Fine Motor referral cutoff score is 29.62 at 4 months of age; 37.97 at 10 months of age; 34.50 at 12 months of age.
46 The ASQ-3 Problem Solving referral cutoff score is 34.98 at 4 months of age; 32.51 at 10 months of age; 27.32 at 12 months of age.
47 The ASQ-3 Personal-Social referral cutoff score is 33.16 at 4 months of age; 27.25 at 10 months; 21.73 at 12 months.
48 The ASQ:SE referral cutoff score is 48 at 12 months of age.
41
Minnesota Department of Health
06112015 page 25
Benchmark Construct
Performance Indicator
32-Number of families that
required services &
received a referral to
available community
resources (6.2)
Percent of infants /children
identified for
developmental or socialemotional delays, referred
to relevant community
resources
Minnesota Department of Health
Operational Definition
Process Indicator – Referrals to
community resources (include
differentiation/definition for Part
C/Part B) for further assessment
&/or services
Target population: All infants
enrolled
Numerator: Number of infants
scoring below the referral cutoff
score for any developmental
milestone, including the
Communication, Gross Motor, Fine
Motor, Problem Solving, or PersonalSocial areas on the ASQ-3 or scoring
above the referral cutoff score for
social-emotional milestones on the
ASQ:SE who were referred to relevant
community resources
Denominator: Total number of infants
who scored below the referral cutoff
score for any developmental
milestone, including the
Communication, Gross Motor, Fine
Motor, Problem Solving, or PersonalSocial areas on the ASQ-3 or who
scored above the referral cutoff score
for social-emotional milestones on
the ASQ:SE
Question or Measurement
Definition of
Tool
Improvement
ASQ-3 & ASQ:SE
Increase percent of infants
who scored below the
Question:
referral cutoff score for
Was the infant referred to
Communication, Gross
relevant community
Motor, Fine Motor, Problem
resources for scoring below
Solving, or Personal-Social
the referral cutoff score for
on the ASQ-3 at 10/12
Communication, Gross
months postpartum or who
Motor, Fine Motor, Problem
scored above the referral
Solving, or Personal-Social
cutoff score on the ASQ:SE
areas on the ASQ-3?
at 12 months postpartum
who received a referral to
Was the infant referred to
relevant community
relevant community
services; Years 2 & 3 crossresources for scoring above
sectional comparisons
the referral cutoff score on
the ASQ:SE?
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Home visitor
charts
Frequency of
data collection:
12 months
postpartum
NFP:
(Calculated variable)
Infant Health Care (#16);
Home Visit Encounter or
Alternative Encounter
(Referral for #26 Early
Childhood Intervention)
06112015 26
Benchmark Construct
33-Number of formal
agreements (including
MOUs) with communitybased agencies in the
collaborating community at
level of reporting entity
(6.3)
34-Information sharing:
Number of agencies which
home visitor has a clear
point of contact at the
community level (6.4)
Performance Indicator
Number of formal
agreements (MOUs)
Number of agencies with
which home visitor has a
clear point of contact at the
community level
Minnesota Department of Health
Operational Definition
Process indicator – Increase in
formal agreements with
community-based agencies
Target population: Community-based
agencies
Numerator: Total number of formal
agreements (including MOUs) with
community-based agencies
Process Indicator – Increase in
number of agencies with a clear
point of contact at the community
level
Target population: Community
agencies
Numerator: Total number of agencies
with a clear point of contact defined
by a name, title, telephone number,
mailing, email address, website, etc.
Question or Measurement
Tool
Question:
Administrative, agency
records, formal agreements
(including MOUs)
Question:
Administrative, agency
records, collected annually,
to include name, title,
telephone number,
mailing/email address,
website, etc.
Definition of
Improvement
Increase in number of
formal agreements (MOUs)
with community-based
agencies; Years 1 & 3 crosssectional comparisons
Increase in number of
agencies with a clear point
of contact at the community
level; Years 1 & 3 crosssectional comparisons
Data Collection
Plan
Data collected
by:
Home
visitor/other
agency-appointed
data staff
Data source:
Administrative/
agency records
Frequency of
data collection:
Year-end 1, 2, 3
Data collected
by:
Home
visitor/other
agency-appointed
data staff
Data source:
Administrative/
agency records
Frequency of
data collection:
Year-end 1, 2, 3
06112015 27
Benchmark Construct
35-Number of completed
referrals - i.e., home visitor
able to track individual
family referrals & assess
their completion, by
obtaining a report date of
service provided (6.5)
Performance Indicator
Percent of infants referred
to community resources for
developmental or socialemotional delays who had
an appointment made for
further screening
Minnesota Department of Health
Operational Definition
Process Indicator –
Infants/children referred to
community resources after not
meeting developmental/socialemotional milestones, receiving
further assessment
Target population: All infants
enrolled
Numerator: Number of infants
scoring below the referral cutoff
score for any developmental
milestone, including the
Communication, Gross Motor, Fine
Motor, Problem Solving, or PersonalSocial areas on the ASQ-3 or scoring
above the referral cutoff score for
social-emotional milestones on the
ASQ:SE who had an appointment
made for further screening
Denominator: Total number of infants
scoring below the referral cutoff
score for any developmental
milestone, including the
Communication, Gross Motor, Fine
Motor, Problem Solving, or PersonalSocial areas on the ASQ-3 or scoring
above the referral cutoff score for
social-emotional milestones on the
who were referred to relevant
community resources
Question or Measurement
Tool
Question:
Did the primary caregiver
make an appointment for
further screening for the
infant referred to relevant
community resources?
NFP:
(Calculated variable)
Infant Health Care (#16);
Home Visit Encounter or
Alternative Encounter
(Referral for #26 Early
Childhood Intervention);
Use of Government &
Community Services
(Receipt of service for #26
Early Childhood
Intervention)
Definition of
Improvement
Increase in percent of
infants scoring below the
referral cutoff score for any
developmental milestone,
including the
Communication, Gross
Motor, Fine Motor, Problem
Solving, or Personal-Social
areas on the ASQ-3 at 10/12
months postpartum or
scoring above the referral
cutoff score for socialemotional milestones on the
ASQ:SE who had an
appointment made for
further screening at 12
months postpartum; Years
2 & 3 cross-sectional
comparisons
Data Collection
Plan
Data collected
by:
Home visitor
Data source:
Client self-report;
Home visitor
chart audits
Frequency of
data collection:
12 months
postpartum
06112015 28
Demographics
Variable
Caregiver
Infant/child
Age (Calculated variable using Date of Birth)
x
x
Hispanic or Latino/a ethnicity
x
x
Race
Gender
Marital status
Primary language
Household members who currently serve in the Armed
Forces
Current enrollment in an educational program (if yes,
specify)
Highest level of education attained
Current employment status
Household size
Federal poverty guideline (FPG) percentage 49
Weeks pregnant at intake
Number of previous live births
Insurance status and major medical care resource
Number of home visits
49
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Calculated using household size and imputed income & benefits (median of categorical annual income & benefits bracket)
Minnesota Department of Health
Data Collection Plan (Frequency of data collection)
Intake (caregiver), 1st postpartum visit (infant/child)
NFP: Demographics Pregnancy Intake (#1), Infant Birth
Intake (caregiver), 1st postpartum visit (infant/child)
NFP: Demographics Pregnancy Intake (#3), Infant Birth (#2)
Intake (caregiver), 1st postpartum visit (infant/child)
NFP: Demographics Pregnancy Intake (#2), Infant Birth (#1)
Intake (caregiver), 1st postpartum visit (infant/child)
NFP: Demographics Pregnancy Intake; Infant Birth (#3)
Intake; NFP: Demographics Pregnancy, Intake (I.5, I.2, II.4-10, II.12) ;
Demographics Update (#1, #4-10, 14)
Intake; NFP: Demographics Pregnancy Intake (I.5)
Intake; NFP: Demographics Pregnancy Intake (II.5) , Demographics Update
(#5)
Intake; NFP: Demographics Pregnancy Intake (II.6, II.8, II.9),; Demographics
Update (#6, #8, #9)
Intake; NFP: Demographics Pregnancy Intake (II.7, II.10), Demographics
Update (#7, #10)
Intake; NFP: Demographics Pregnancy Intake (I.12), Demographics Update
(#14)
Intake
Intake
Intake
Intake; NFP: Maternal Health Assessment (#1)
Intake; 1st postpartum visit, 6, 12, 18, 24 months postpartum
NFP: Use of Government & Community Services (Receipt of service for #1316 insurance plans)
Intake; 1st postpartum visit, 6, 12, 18, 24 months postpartum
NFP: Home Visitor Encounter, Alternative Encounter
06112015 page 29
Service Utilization
Family retention 50
50
Variable
x
Caregiver
Infant/child
Data Collection Plan (Frequency of data collection)
Discharge; NFP: Client Discharge
Clients will be categorized into “completed program”, “stopped services for person reason”, “program unable to provide services”, and “loss of follow-up”.
Minnesota Department of Health
06112015 30