Exhibit E - MIECHV Data Examples.pdf

OMB No: 0906-0016 Expiration date: 09/30/2027

OMB Approved: 9/24/2024

THE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING

PROGRAM

FORM 4

QUARTERLY PERFORMANCE REPORT

Public Burden Statement: The purpose of this collection is to collect performance measures from Maternal, Infant, and Early Childhood Home Visiting (MIECHV) awardees. HRSA will use the proposed information to demonstrate program accountability and quarterly monitor and provide oversight to MIECHV Program awardees. The information will also be used to provide quality improvement guidance and technical assistance to awardees and help inform the development of early childhood systems at the national, state, and local level. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0016 and it is valid until 09/30/2027. This information collection is required to obtain or retain a benefit (42 U.S.C. 701). Data will be private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average 21 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grantees are required to submit the information outlined below on a quarterly basis.

Quarterly reporting periods are defined as follows. Reports are due 45 days after the end of each reporting period:

• Q1 – October 1 - December 31;

• Q2 – January 1 - March 31;

• Q3 – April 1 - June 30;

• Q4 – July 1 - September 30

Definitions for key terms are included in Appendix A. Please carefully consult key term definitions before completing this form.

Grant Number(s):

Section A:

Table A.1: Program Capacity

Column A Column B Column C Column D Column E Number of New Households Enrolled

Number of Continuing Households

Current Caseload (A+B) (Auto-Calculate)

Maximum Service Capacity

Capacity Percentage (C÷D) (Auto-Calculate)

Table A.2: Place-Based Services

Add a row for each Local Implementing Agency (LIA) providing services during the reporting period. For each LIA, add the address of the LIA, the counties served by that LIA, and the evidence-based home visiting model(s) or promising approaches implemented by the LIA.

Column A Column B Column C*** Column D*** Local Implementing Agency (LIA) Organization Name

LIA Address* Counties** Evidence-Based Home Visiting Models or Promising Approaches

*Address should represent the physical address of the organization’s main office and may not reflect the service delivery area.

The address is not used by HRSA to determine a LIAs service delivery area.

**Note that the same county can be served by multiple LIAs.

***Additional rows can be added if needed.

Table A.3: Family Engagement

Column A1 Column B Column C Column D Column E Number of Households Currently Receiving Services

Number of Households who Completed Program

Number of Households who Stopped Services Before Completion

Other Total (A+B+C+D) (Auto- Calculate)

1 Validation: Column A should equal Table A.1. columns A and B

Table A.4: Staff Recruitment and Retention

Column A Column B Column C Number of FTE MIECHV Home Visitors

Number of FTE MIECHV Supervisors

Number of FTE MIECHV Other Staff

Notes:

DEFINITIONS OF KEY TERMS

Table Number

Field Key Terms Requiring Definitions

A.1 Program Capacity New Household: A household, including a pregnant participant and/or caregiver, who signs up to participate in the home visiting program at any time during the reporting period and continues enrollment during the reporting period.

The household may include multiple caregivers depending on model-specific definitions.

Continuing Household: A household, including a pregnant participant and/or caregiver who were signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period and continues enrollment during the reporting period. The household may include multiple caregivers depending on model-specific definitions.

Current Caseload: The number of households actively enrolled at the end of the quarterly reporting period. All members of one household represent a single caseload slot.

Maximum Service Capacity: The highest number of households that could potentially be enrolled at the end of the quarterly reporting period if the program were operating with a full complement of hired and trained home visitors

Note: The maximum service capacity is equivalent to the caseload of family slots approved by HRSA

Caseload of Family Slots: The highest number of families (or households) that could potentially be enrolled at any given time if the program were operating with a full complement of hired and trained home visitors.

Family slots are those enrollment slots identified as MIECHV in accordance with the identified enrollment method of the awardee. For more information on the definition of a MIECHV family slot see the FY 2108 MIECHV Notice of Funding Opportunity Announcement. All members of one family or household represent a single caseload slot. The count of slots should be distinguished from the cumulative number of enrolled families during the grant period. It is known that the caseload of family slots may vary by federal fiscal year pending variation in available funding in each fiscal year. Applicants should remember that inability to meet proposed caseloads may results in deobligated funds, which may impact future funding.

Capacity Percentage: Capacity percentage is a calculated indicator that results from dividing the current caseload by the maximum service capacity and multiplying by 100.

Table Number

Field Key Terms Requiring Definitions

A.2 Place-Based Services LIA Organization Name: Each LIA organization name should reflect a unique and distinct local implementing agency. There should not be duplicate LIA submissions. If an LIA has multiple locations or sites, the LIA organization name should represent service delivery across all locations.

LIA Address: Only one address should be entered per LIA. The LIA address should reflect the physical address of the organization’s main office, which may not directly reflect the service delivery area. If an LIA has multiple locations or addresses and does not have a physical main office location, report the LIA address that most accurately reflects where services are delivered.

Counties: Counties should reflect geographic distribution of households served by the LIA during the quarterly reporting period.

Evidence-Based Home Visiting Models or Promising Approaches: Information submitted should reflect evidence-based home visiting model(s) implemented by the LIA. For LIAs implementing multiple models during the quarterly reporting period, all models implemented should be recorded for that LIA.

A.3 Family Engagement Currently Receiving Services: The number of households currently receiving services refers to households that are participating in services at the end of the reporting period.

Completed Program: The number of households who completed the program refers to households who have completed the program or transitioned to another program according to home visiting model-specific definitions and criteria during the reporting period.

Stopped Services Before Completion: The number of households who stopped services before completion refers to households who left the program for any reason prior to completion.

Other: Other refers to those households who do not fall into the previous categories and may include unreachable participants (i.e., the family is not regularly participating but did not actively sever ties, etc.)

A.4 Staffing Full Time Equivalent Home Visitor/Supervisor/Other Staff: A full time equivalent home visitor(s)/supervisor(s)/other staff who is employed with a contracted local implementing agency at the end of the quarterly reporting period. Awardees should only report the proportion of the FTE that is supported by MIECHV grant funds.

For example, a 1.0 FTE staff member who is supported at 30% through MIECHV funds and 70% through other funds would be reported as a 0.3 FTE for the purposes of the table.

OMB No: 0906-0017 Expiration Date: 09/30/2027

THE MATERNAL, INFANT, AND EARLY CHILDHOOD

HOME VISITING PROGRAM

FORM 2

PERFORMANCE AND SYSTEMS OUTCOME

MEASURES

Public Burden Statement: The purpose of this collection is to collect demographic, performance, and system outcomes measures from Maternal, Infant, and Early Childhood Home Visiting (MIECHV) awardees. HRSA will use the proposed information to demonstrate program accountability and annually monitor and provide oversight to MIECHV Program awardees. The information will also be used to provide quality improvement guidance and technical assistance to awardees and help inform the development of early childhood systems at the national, state, and local level. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0017 and it is valid until 9/30/2027. This information collection is required to obtain or retain a benefit (42 U.S.C. 701). Data will be private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average 390.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

mailto:paperwork@hrsa.gov https://www.hrsa.gov/about/508-resources

MEASURE 1

1.

BENCHMARK AREA: MATERNAL AND NEWBORN HEALTH

CONSTRUCT: PRETERM BIRTH

2.

TYPE OF MEASURE

Systems Outcome

3.

PERFORMANCE MEASURE

Percent of infants (among mothers who enrolled in home visiting prenatally before 37 weeks) who are born preterm following program enrollment

4.

SPECIFICATION

NUMERATOR: Number of live births (index child or subsequent children among mothers who enrolled in home visiting prenatally before 37 weeks) born before 37 completed weeks of gestation and after enrollment

DENOMINATOR: Number of live births after enrollment who were born to mothers enrolled in home visiting prenatally before 37 weeks

5.

VALUE FOR REPORTING PERIOD (percentage)

Value:

Numerator:

Denominator:

6.

MISSING DATA*

6.a. Definition

Data are considered missing if one or more data elements needed to determine inclusion in the numerator or denominator are unknown. All cases of missing data should be excluded from the measure calculation.

6.b. Value – Enter the number of cases missing from measure calculation:

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

MEASURE 2

CONSTRUCT: BREASTFEEDING

Percent of infants (among mothers who enrolled in home visiting prenatally) who were breastfed any amount at 6 months of age

4.

SPECIFICATION

NUMERATOR: Number of infants aged 6-12 months (index child among mothers who enrolled in home visiting prenatally) who were breastfed any amount at 6 months of age

DENOMINATOR: Number of infants aged 6-12 months (index child among mothers who enrolled in home visiting prenatally) enrolled in home visiting for at least 6 months

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. All cases of missing data should be excluded from the measure calculation.

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 3

CONSTRUCT: DEPRESSION SCREENING

Performance Indicator

Percent of primary caregivers enrolled in home visiting who are screened for depression using a validated tool within 3 months of enrollment (for those not enrolled prenatally) or within 3 months of delivery (for those enrolled prenatally)

4.

SPECIFICATION

NUMERATOR: For those not enrolled prenatally, number of primary caregivers enrolled in home visiting who are screened for depression within the first 3 months since enrollment; for those enrolled prenatally, the number of primary caregivers screened for depression within 3 months of delivery

DENOMINATOR: For those not enrolled prenatally, the number of primary caregivers enrolled in home visiting for at least 3 months; for those enrolled prenatally, the number of primary caregivers enrolled in home visiting for at least three months post delivery

Denominator:

6.

elements needed to determine inclusion in the numerator or denominator are unknown. When there is no documentation of whether a screening occurred using a validated tool, but all other data elements are known, then the primary caregiver should be included in the denominator (if eligible), but not in the numerator. All cases of missing data should be excluded from the measure calculation.

6.b. Value – Enter the number of cases missing from measure calculation:

7.

NOTES

8. Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 4

CONSTRUCT: WELL CHILD VISIT

PERFORMANCE MEASURE

Percent of children enrolled in home visiting who received the last recommended visit based on the American Academy of Pediatrics (AAP) schedule

NUMERATOR: Number of children (index child) enrolled in home visiting who received the last recommended well child visit based on the AAP schedule

DENOMINATOR: Number of children (index child) enrolled in home visiting

Denominator:

6.

numerator or denominator are unknown, including if a home visit occurred but the home visitor did not collect the data. All cases of missing data should be excluded from the measure calculation.

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 5

CONSTRUCT: POSTPARTUM CARE

Percent of mothers enrolled in home visiting prenatally or within 30 days after delivery who received a postpartum visit with a healthcare provider within 8 weeks (56 days) of delivery

4.

SPECIFICATION

NUMERATOR: Number of mothers enrolled in home visiting prenatally or within 30 days after delivery who received a postpartum visit with a healthcare provider within 8 weeks (56 days) of delivery

DENOMINATOR: Number of mothers who enrolled in home visiting prenatally or within 30 days after delivery and remained enrolled for at least 8 weeks (56 days) after delivery

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. All cases of

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 6

CONSTRUCT: TOBACCO CESSATION REFERRALS

TYPE OF MEASURE

Performance Indicator

Percent of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes at enrollment and were referred to tobacco cessation counseling or services within 3 months of enrollment.

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes enrollment and were referred to tobacco cessation counseling or services within 3 months of enrollment

DENOMINATOR: Number of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes at enrollment and were enrolled for at least 3 months

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown, including if there is no documentation of whether the primary caregiver used tobacco or cigarettes at enrollment since inclusion in the denominator cannot be determined if the screening result is unknown. When there is no documentation of whether a referral was provided, but all other data elements are known and inclusion in the denominator can be determined, then the primary caregiver should be included in the denominator (if eligible), but not in the numerator.

All cases of missing data should be excluded from the measure calculation.

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 7

BENCHMARK AREA: CHILD INJURIES, ABUSE, NEGLECT, AND MALTREATMENT AND EMERGENCY

DEPARTMENT VISITS

CONSTRUCT: SAFE SLEEP

2.

TYPE OF MEASURE

Performance Indicator

Percent of infants enrolled in home visiting that are always placed to sleep on their backs, without bed-sharing and without soft bedding

NUMERATOR: Number of infants (index child aged less than 1 year) enrolled in home visiting whose primary caregiver reports that they are always placed to sleep on their backs, without bed-sharing and without soft bedding

DENOMINATOR: Number of infants (index child) enrolled in home visiting who were aged less than 1 year during the reporting period

Denominator:

6.

numerator or denominator are unknown. All cases of

7.

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 8

DEPARTMENT VISITS

CONSTRUCT: CHILD INJURY

2.

TYPE OF MEASURE

Systems Outcome

Rate of injury-related visits to the Emergency Department (ED) during the reporting period among children enrolled in home visiting

NUMERATOR: Number of parent-reported nonfatal injury-related visits to the ED during the reporting period among children (index child) enrolled in home visiting

DENOMINATOR: Number of children (index child) enrolled in home visiting

VALUE FOR REPORTING PERIOD (rate)

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. All cases of

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 9

DEPARTMENT VISITS

CONSTRUCT: CHILD MALTREATMENT

2.

TYPE OF MEASURE

Systems Outcome

Percent of children enrolled in home visiting with at least 1 investigated case of maltreatment following enrollment within the reporting period

NUMERATOR: Number of children (index child) enrolled in home visiting with at least 1 investigated case of maltreatment following enrollment within the reporting period

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. All cases of

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 10

BENCHMARK AREA: SCHOOL READINESS AND ACHIEVEMENT

CONSTRUCT: PARENT-CHILD INTERACTION

Percent of primary caregivers enrolled in home visiting who receive an observation of caregiver-child interaction by the home visitor using a validated tool

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers enrolled in home visiting who receive an observation of caregiver-child interaction by the home visitor using a validated tool

DENOMINATOR: Number of primary caregivers enrolled in home visiting with children reaching the target age range

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. When there is no documentation of whether the index child received an observation of caregiver-child interaction by the home visitor using a validated tool, but all other data elements are known, then the index child should be included in the denominator (if eligible), but not in the numerator. All cases of

8.

Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 11

CONSTRUCT: EARLY LANGUAGE AND LITERACY ACTIVITIES

Percent of children enrolled in home visiting with a family member who reported that during a typical week s/he read, told stories, and/or sang songs with their child daily, every day

4.

SPECIFICATION

NUMERATOR: Number of children (index child) enrolled in home visiting with a family member who reported that during a typical week s/he read, told stories, and/or sang songs with their child daily, every day

Denominator:

numerator or denominator are unknown. All cases of

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 12

CONSTRUCT: DEVELOPMENTAL SCREENING

Percent of children enrolled in home visiting with a timely screen for developmental delays using a validated parent-completed tool

4.

SPECIFICATION

NUMERATOR: Number of children (index child) enrolled in home visiting with at least one screening within the AAP-defined age groups during the reporting period

DENOMINATOR: Number of children (index child) enrolled in home visiting reaching the specified time frame during the reporting period

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. When there is no documentation of whether a screening occurred using a validated tool, but all other data elements are known, then the child should be included in the denominator (if eligible), but not in the numerator. All cases of missing data should be excluded from the measure calculation.

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

8.

Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

MEASURE 13

CONSTRUCT: BEHAVIORAL CONCERN INQUIRIES

Percent of postnatal home visits where primary caregivers were asked if they have any concerns regarding their child’s development, behavior, or learning

4.

SPECIFICATION

NUMERATOR: Number of postnatal home visits where primary caregivers enrolled in home visiting were asked if they have any concerns regarding their child’s development, behavior, or learning

DENOMINATOR: Total number of postnatal home visits during the reporting period

Denominator:

MISSING DATA

numerator or denominator are unknown. If a home visit occurred, but there is no documentation of whether the primary caregiver was asked about behavioral concerns, then the home visit should be included in the denominator (if eligible – i.e., postnatal visit), but not in the numerator. All cases of

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 14

BENCHMARK AREA: CRIME OR DOMESTIC VIOLENCE

CONSTRUCT: INTIMATE PARTNER VIOLENCE SCREENING

Percent of primary caregivers enrolled in home visiting who are screened for intimate partner violence (IPV) within 6 months of enrollment using a validated tool

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers enrolled in home visiting who are screened for IPV using a validated tool within 6 months of enrollment

DENOMINATOR: Number of primary caregivers enrolled in home visiting for at least 6 months

Denominator:

numerator or denominator are unknown. When there is no documentation of whether a screening occurred using a validated tool (including if a screening did not occur because the caregiver was male and they only have validated tools for use among female caregivers), but all other data elements are known, then the primary caregiver should be included in the denominator (if eligible), 8.

Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 15

BENCHMARK AREA: FAMILY ECONOMIC SELF-SUFFICIENCY

CONSTRUCT: PRIMARY CAREGIVER EDUCATION

Percent of primary caregivers who enrolled in home visiting without a high school degree or equivalent who subsequently enrolled in or maintained continuous enrollment in middle school or high school, or completed high school or equivalent during their participation in home visiting

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers who enrolled in or maintained continuous enrollment in middle school or high school, or completed a high school degree or equivalent after enrollment in home visiting (and met the conditions specified in the denominator)

DENOMINATOR: Number of primary caregivers without a high school degree or equivalent at enrollment

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. All cases of

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

MEASURE 16

BENCHMARK AREA: FAMILY ECONOMIC SELF-SUFFICIENCY

CONSTRUCT: CONTINUITY OF INSURANCE COVERAGE

Percent of primary caregivers enrolled in home visiting for at least 6 months who had continuous health insurance coverage for the most recent 6 consecutive months

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers enrolled in home visiting who reported having continuous health insurance coverage for the most recent 6 consecutive months at the most recent data collection time point in the reporting period

DENOMINATOR: Number of primary caregivers enrolled in home visiting for at least 6 months

Denominator:

numerator or denominator are unknown. All cases of

7.

NOTES

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 17

BENCHMARK AREA: COORDINATION AND REFERRALS FOR OTHER COMMUNITY RESOURCES AND

SUPPORTS

CONSTRUCT: COMPLETED DEPRESSION REFERRALS

2.

TYPE OF MEASURE

Systems Outcome

Percent of primary caregivers referred to services for a positive screen for depression who receive one or more service contacts

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers enrolled in home visiting who received recommended services for depression (and met the conditions specified in the denominator)

DENOMINATOR: Number of primary caregivers enrolled in home visiting who had a positive screen for depression within 3 months of enrollment (for those not enrolled prenatally) or within 3 months of delivery (for those enrolled prenatally) and were referred for services

Denominator:

6.

numerator or denominator are unknown. Data are also considered missing if there is no documentation of whether a referral was provided. All cases of

8.

Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 18

SUPPORTS

CONSTRUCT: COMPLETED DEVELOPMENTAL REFERRALS

2.

TYPE OF MEASURE

Systems Outcome

Percent of children enrolled in home visiting with positive screens for developmental delays (measured using a validated tool) who receive services in a timely manner

4.

SPECIFICATION

NUMERATOR: Number of children enrolled in home visiting who a) received individualized developmental support from a home visitor; b) were referred to early intervention services and receive an evaluation within 45 days; OR c) were referred to other community services who received services within 30 days (and met the condition specified in the denominator)

DENOMINATOR: Number of children enrolled in home visiting with positive screens for developmental delays (measured using a validated tool)

Denominator:

6.

numerator or denominator are unknown. When there is no documentation of whether a referral was provided, but all other data elements are available and inclusion in the denominator can be determined, then the primary caregiver should be included in the denominator (if eligible), but not in the numerator.

All cases of missing data should be excluded from the measure calculation.

7. NOTES

8.

Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

MEASURE 19

SUPPORTS

CONSTRUCT: INTIMATE PARTNER VIOLENCE REFERRALS

2.

TYPE OF MEASURE

Performance Indicator

Percent of primary caregivers enrolled in home visiting with positive screens for IPV (measured using a validated tool) who receive referral information to IPV resources

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers enrolled in home visiting who received referral information to IPV resources (and met the conditions specified in the denominator)

DENOMINATOR: Number of primary caregivers enrolled in home visiting with positive screens for IPV (measured using a validated tool) within 6 months of enrollment

Denominator:

elements needed to determine inclusion in the numerator or denominator are unknown. When there is no documentation of whether a referral was provided, but all other data elements are available and inclusion in the denominator can be determined, then the primary caregiver should be included in the denominator (if eligible), but not in the numerator.

All cases of missing data should be excluded from the measure calculation.

8.

Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

OPTIONAL MEASURE 1

CONSTRUCT: SUBSTANCE USE SCREENING

Percent of primary caregivers enrolled in home visiting who are screened for both unhealthy alcohol use and drug use using a validated tool within 6 months of enrollment

NUMERATOR: Number of primary caregivers enrolled in home visiting who were screened for both unhealthy alcohol use and drug use using validated tool(s) within 6 months of enrollment

DENOMINATOR: Number of primary caregivers enrolled in home visiting for at least 6 months

Denominator:

6.

numerator or denominator are unknown. When there is no documentation of whether a screening occurred using a validated tool, but all other data elements are known, then the primary caregiver should be included in the denominator (if eligible),

8. Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

OPTIONAL MEASURE 2

SUPPORTS

CONSTRUCT: COMPLETED SUBSTANCE USE REFERRALS

2.

TYPE OF MEASURE

Systems Outcome

Percent of primary caregivers referred to services for a positive screen for substance use who receive one or more service contacts

4.

SPECIFICATION

NUMERATOR: Number of primary caregivers enrolled in home visiting who received recommended services for substance use (and met the conditions specified in the denominator)

DENOMINATOR: Number of primary caregivers enrolled in home visiting who had a positive screen for unhealthy alcohol use and/or drug use (measured using a validated tool) within 6 months of enrollment and were referred for services

Denominator:

6.

numerator or denominator are unknown. Data are also considered missing if there is no documentation of whether a referral was provided. All cases of

8.

Measurement Tool Utilized

Indicate the validated measurement tool(s) utilized to address this measure

* Note: When the percent of missing data is ≥10%, a table note should be provided that addresses the reason for the

Expiration Date: 07/31/2024

Construct Number

Construct Key Term Definitions

1. Preterm Birth Preterm Birth: a birth before 37 completed weeks of gestation (defined as up to 36 weeks and 6 days).1

2. Breastfeeding Breastfeeding: in addition to breast milk fed directly from the mother to the infant, breastfeeding also includes feeding the infant pumped or expressed breast milk.

3. Depression Screening

Depression: aligned with each grantee’s validated depression screening tool’s definition of depression.

4. Well-Child Visit AAP schedule for Well-Child Visits: Updated AAP 2017 Recommendations for Pediatric Preventive Health Care https://www.aap.org/en-us/Documents/periodicity_schedule.pdf

5. Postpartum Care Postpartum Care Visit: A postpartum visit is a visit between the woman and her health care provider to assess the mother’s current physical health, including the status of pregnancy-related conditions like gestational diabetes, screen for postpartum depression, provide counseling on infant care and family planning as well as screening and referrals for the management of chronic conditions. Additionally, a provider may use this opportunity to conduct a breast exam and discuss breastfeeding. The American College of Obstetricians and Gynecologists recommends that mothers receive a postpartum care visit within 6 weeks after delivery. 2

6. Tobacco Cessation Referrals

Tobacco Use: combustibles (cigarettes, cigars, pipes, hookahs, bidis), non-combustibles (chew, dip, snuff, snus, and dissolvables), and ENDS.

7. Safe Sleep No definitions required

8. Child Injury Injury-related Emergency Department Visit: Injuries refer to the following causes of mechanisms of injury: motor vehicle, suffocation, drowning, poisoning, fire/burns, falls, sports and recreation, and intentional injuries, such as child maltreatment.3

9. Child Maltreatment

Investigated Case: all children with an allegation of maltreatment that were screened-in for investigation or assessment and further received an investigation. 4 A screened-in report is one that is accepted for investigation or assessment based on the state’s screen-in criteria. 5

10. Parent-Child Interaction

No definitions required

11. Early Language and Literacy Activities

No definitions required

12. Developmental Screening

Developmental Delay: delays in any or all areas including cognitive, social, language, sensory, 1 Behrman R, Stith Butler A. eds. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: The National Academies Press, 2007.

2 Optimizing postpartum care. Committee Opinion No. 666. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e187–92. Retrieved from https://www.acog.org/- /media/Committee-Opinions/Committee-on-Obstetric-Practice/co666.pdf?dmc=1&ts=20180221T1421452301 3 Centers for Disease Control and Prevention. National Action Plan for Child Injury Prevention. 2012. Retrieved from http://www.cdc.gov/safechild/NAP/background.html#unint 4 Child Welfare Information Gateway. Child Maltreatment 2015: Summary of Key Findings. Retrieved from https://www.childwelfare.gov/pubs/factsheets/canstats/ 5 Child Welfare Information Gateway. Screening and Intake. Retrieved from https://www.childwelfare.gov/topics/responding/iia/screening/ http://www.aap.org/en-us/Documents/periodicity_schedule.pdf http://www.acog.org/-http://www.cdc.gov/safechild/NAP/background.html#unint https://www.childwelfare.gov/pubs/factsheets/canstats/ https://www.childwelfare.gov/topics/responding/iia/screening/ and emotional development.6

13. Behavioral Concern Inquiries

No definitions required

14. IPV Screening Intimate Partner Violence: physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner. An intimate partner is a person with whom one has a close personal relationship that can be characterized by the following: emotional connectedness, regular contact, ongoing physical contact and sexual behavior, identity as a couple, familiarity and knowledge about each other’s lives. 7

15. Primary Caregiver Education

No definitions required

16. Continuity of Insurance Coverage

Continuous Health Insurance Coverage: having health insurance coverage without any lapses.

17. Completed Depression Referrals

Recommended services: specific techniques and intervention models delivered in the context of client characteristics, culture, and preferences that have shown to have positive effects on outcomes through rigorous evaluations and have demonstrated to achieve positive outcomes for the client.8

18. Completed Developmental Referrals

Developmental Delay: delays in any or all areas including cognitive, social, language, sensory, and emotional development.6

19. IPV Referrals Intimate Partner Violence: physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner. An intimate partner is a person with whom one has a close personal relationship that can be characterized by the following: emotional connectedness, regular contact, ongoing physical contact and sexual behavior, identity as a couple, familiarity and knowledge about each other’s lives. 7

Optional Measure 1

Substance Use Screenings

Unhealthy Alcohol Use and Drug Use: Definitions of unhealthy alcohol and drug use should align with each awardees’s validated substance use screening tool’s definition.

Optional Measure 2

Completed Substance Use Referrals

Recommended services: Specific techniques and intervention models delivered in the context of client characteristics, culture, and preferences that have shown to have positive effects on outcomes through rigorous evaluations and have demonstrated to achieve positive outcomes for the client. 8

6 U.S. National Library of Medicine, National Institutes of Health. Psychological Index Terms via Unified Medical Language System, 2015. Retrieved from http://ghr.nlm.nih.gov/glossary=developmentaldelay 7 Centers for Disease Control and Prevention. Injury Prevention and Control: Division of Violence Prevention, 2015. Retrieved from http://www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html 8 Home Visiting Collaborative Improvement and Innovation Network.

http://ghr.nlm.nih.gov/glossary%3Ddevelopmentaldelay http://www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html

Expiration Date: 9/30/2027

THE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING

PROGRAM

FORM 1

DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL

INDICATORS

Public Burden Statement: The purpose of this collection is to collect demographic, performance, and system outcomes measures from Maternal, Infant, and Early Childhood Home Visiting (MIECHV) awardees. HRSA will use the proposed information to demonstrate program accountability and annually monitor and provide oversight to MIECHV Program awardees. The information will also be used to provide quality improvement guidance and technical assistance to awardees and help inform the development of early childhood systems at the national, state, and local level. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0017 and it is valid until 9/30/2027. This information collection is required to obtain or retain a benefit (42 U.S.C. 701). Data will be private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average 390.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

mailto:paperwork@hrsa.gov

SECTION A: PARTICIPANT DEMOGRAPHICS

Table 1: Unduplicated Count of New and Continuing Program Participants Served by MIECHV

Participants Number Newly Enrolled Number Continuing During Reporting Period Total Pregnant Participants Caregivers All Adults (Auto Calculate) All Index Children

Notes:

Table 2: Unduplicated Count of Households Served by MIECHV

Households Number Newly Enrolled Number Continuing During Reporting Period Total Number of Households

Notes:

Table 3: Unduplicated Count of Participants and Households Served by State Home Visiting Programs (non-MIECHV)

Participants and Households Total Number Served during Reporting Period Pregnant Participants Caregivers All Adults (Auto Calculate) All Index Children Number of Households

Table 4: Adult Participants by Age

Adult Participants ≤17 18-19 20-21 22-24 25-29 30-34 35-44 45-54 55-64 ≥65 Unknown/Did not Report*

Total

Newly Enrolled Pregnant Participants Newly Enrolled Caregivers Continuing Pregnant Participants Continuing Caregivers All Adults (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 5: Index Children by Age

Index Children <1 year 1-2 years 3-4 years 5-6 years Unknown/Did not Report* Total Newly Enrolled Index Children Continuing Index Children All Index Children (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 6: Participants by Ethnicity

Participants Hispanic or Latino Not Hispanic or Latino Unknown/Did not Report* Total Pregnant Participants Caregivers All Adults (Auto Calculate) All Index Children

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Table 7: Participants by Race

Participants American Indian or Alaska Native

Asian Black or African American

Native Hawaiian or Other Pacific Islander

White More than one race

Unknown/Did not Report*

Total

Pregnant Participants Caregivers All Adults (Auto

All Index Children

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 8: Adult Participants by Marital Status

Adult Participants

Never Married (Excluding Not Married but Living Together with Partner)

Married Not Married but Living Together with Partner

Separated/Divorced/Widowed Unknown/Did not Report*

Total

Pregnant Participants

Caregivers

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Table 9: Adult Participants by Educational Attainment

Adult Participants

Less than

HS

diploma

HS

Diploma/GED

Some college/ training

Technical training or certification

Associate’s Degree

Bachelor’s Degree or higher

Other

Unknown/Did not Report*

Total

Newly Enrolled Pregnant

Newly Enrolled Caregivers Continuing Pregnant

Continuing Caregivers All Adults (Auto

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Notes:

Table 10: Adult Participants by Employment Status

Adult Participants Employed Full Time

Employed Part- Time

Not employed Unknown/Did not Report*

Total

Continuing Pregnant

Continuing Caregivers All Adults (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Table 11: Adult Participants by Housing Status

Not Homeless

Adult Participants Owns or shares own home, condominium, or apartment

Rents or shares own home or apartment

Lives in public housing

Lives with parent or family member

Some other arrangement

Total Not Homeless

Pregnant Participants

Caregivers

Homeless

Adult Participants Homeless and sharing housing

Homeless and living in an emergency or transitional shelter

Some other arrangement Total Homeless

Pregnant Participants Caregivers

Housing Status – Total

Adult Participants Unknown/Did not Report Total Not Homeless Total Homeless Total Pregnant Participants Caregivers All Adults (Auto Calculate)

Notes:

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Table 12: Primary Language Spoken at Home

Index Children Number Percent English Spanish Other Unknown/Did Not Report* All Index Children (Auto Calculate) 100

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 13: Household Income in Relation to Federal Poverty Guidelines

Households Number of Households Percent 50% and under 51-100% 101-133% 134-200% 201-300% >300% Unknown/Did not Report* All Households (Auto Calculate) 100

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Table 14: For Each Household Indicate the Priority Population Characteristics

Households Yes

No

Unknown/Did not Report*

Total

1. Low income household

2. Household contains an enrollee who is pregnant and under age 21

3. Household has a history of child abuse or neglect or has had interactions with child welfare services

4. Household has a history of substance abuse or needs substance abuse treatment

5. Someone in the household uses tobacco products in the home

6. Someone in the household has attained low student achievement or has a child with low student achievement

7. Household has a child with developmental delays or disabilities

8. Household includes individuals who are serving or formerly served in the US armed forces

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

SECTION B: SERVICE UTILIZATION

Table 15: Home Visits

Home Visiting Model (Select One per Row – Add Rows for Additional Models)

In-person Home Visits Virtual Home Visits Unknown/Did Not Report Total

Percent (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Table 16: Family Engagement by Household

Households Number of Households Percent Currently receiving services Completed program Stopped services before completion Enrolled but not currently receiving services/Other Unknown/Did not Report* All Categories (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 17: Unduplicated Count of Households by Evidence-Based Home Visiting Model or Promising Approach

Home Visiting Model (Select One per Row – Add Rows for Additional Models)

Number Newly Enrolled

Number Continuing During Reporting Period

Total

SECTION C: INSURANCE AND CLINICAL INDICATORS

Table 18: Participants by Type of Health Insurance Coverage

Participants No Insurance Coverage

Medicaid or

CHIP

Tri- Care

Private or Other

Unknown/Did not Report*

Total

Continuing Pregnant Participants Continuing Caregivers All Adults (Auto Calculate) All Index Children

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 19: Index Children by Usual Source of Medical Care

Index Children Doctor’s/Nurse Practitioner’s Office

Hospital Emergency Room

Hospital Outpatient

Federally Qualified Health Center

Retail Store or Minute Clinic

Other None Unknown/Did not Report*

Total

Newly Enrolled Index Children

Continuing Index Children

All Index Children (Auto

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Table 20: Index Children (≥ 12 months of age) by Usual Source of Dental Care

Index Children Have a Usual Source of Dental Care

Do not have a Usual Source of Dental Care

Unknown/Did not Report*

Total

Newly Enrolled Index Children Continuing Index Children All Index Children (Auto

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if

Table

Field Key Terms Requiring Definitions

All Tables

MIECHV Household: For the purposes of reporting to HRSA on Form 1, a “MIECHV household” is defined as a family served during the reporting period by a trained home visitor implementing services with fidelity to the model and that is identified as a MIECHV household at enrollment. HRSA has identified two different methods that can be used to identify MIECHV households that are described below:

1. Home Visitor Personnel Cost Method (preferred method): Households are designated as MIECHV at enrollment based on the designation of the home visitor they are assigned. Using this methodology, recipients designate all households as MIECHV that are served by home visitors for whom at least 25 percent of his/her personnel costs (salary/wages including benefits) are paid for with MIECHV funding.

2. Enrollment Slot Method (temporary option): Households are designated as MIECHV households based on the slot they are assigned to at enrollment.