MCHB HRSA-21-050 (X10) MIECHV Formula_OMB-Cleared_Final_MOD_5-12-21.pdf

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Maternal and Child Health Bureau Division of Home Visiting and Early Childhood Systems

Maternal, Infant, and Early Childhood Home Visiting Program – Formula

Funding Opportunity Number: HRSA-21-050 Funding Opportunity Type(s): New

Assistance Listings (CFDA) Number: 93.870

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2021

Letter of Intent for New Applicants Requested by: March 25, 2021

Application Due Date: June 30, 2021

Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

HRSA will not approve deadline extensions for lack of registration.

Registration in all systems, including SAM.gov and Grants.gov, may take up to 1 month to complete.

Issuance Date: March 18, 2021

MODIFIED on May 12, 2021: Extended application due date

Kelsey McCoy, Supervisory Public Health Analyst Division of Home Visiting and Early Childhood Systems Maternal and Child Health Bureau Health Resources and Services Administration 15 New Sudbury Street, Suite 1826 Boston, MA 02203 Telephone: (617) 565-1451 Email: kmccoy@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: 42 U.S.C. § 711(c) (Title V, § 511(c) of the Social Security Act) mailto:kmccoy@hrsa.gov

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EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for the fiscal year (FY) 2021 Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program – Formula. The purpose of this program is to support the delivery of coordinated and comprehensive high-quality and voluntary early childhood home visiting services to eligible families. The goals are to: (1) strengthen and improve the programs and activities carried out under Title V of the Social Security Act; (2) improve coordination of services for at-risk communities; and (3) identify and provide comprehensive services to improve outcomes for eligible families living in at-risk communities. HRSA administers this program in partnership with the Administration for Children and Families (ACF).

Funding Opportunity Title: Maternal, Infant, and Early Childhood

Home Visiting Program – Formula Funding Opportunity Number: HRSA-21-050 Due Date for Applications: June 30, 2021 Anticipated Total Annual Available FY 2021 Funding:

Up to $342 million

Estimated Number and Type of Award(s): Up to 56 grants Estimated Award Amount: Amounts vary Cost Sharing/Match Required: No Period of Performance: September 30, 2021 through

September 29, 2023 (2 years)

Eligible Applicants: Eligible recipients include all states and six territories and jurisdictions serving the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, the Commonwealth of the Northern Mariana Islands, and American Samoa. Nonprofit organizations receiving MIECHV Program

- Formula funding in FY 2020 are also eligible to apply if the state for which they were funded to provide MIECHV services in FY 2020 does not apply.

See Section III.1 of this notice of funding opportunity (NOFO) for complete eligibility information.

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Application Guide

You (the applicant organization/agency) are responsible for reading and complying with the instructions included in HRSA’s SF-424 Application Guide, available online at http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf, except where instructed in this NOFO to do otherwise.

Technical Assistance

HRSA has scheduled the following technical assistance webinar:

Day and Date: Wednesday, March 31, 2021 Time: 3 – 4:30 p.m. ET Call-in number and registration for this webinar will be available here:

https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/program-implementation-and-fiscal-management-resources.

HRSA will record the webinar and archive the recording on the same webpage.

http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/program-implementation-and-fiscal-management-resources https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/program-implementation-and-fiscal-management-resources

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Table of Contents

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. PURPOSE

2. BACKGROUND

II. AWARD INFORMATION

1. TYPE OF APPLICATION AND AWARD

2. SUMMARY OF FUNDING

III. ELIGIBILITY INFORMATION

1. ELIGIBLE APPLICANTS

2. COST SHARING/MATCHING

3. OTHER

IV. APPLICATION AND SUBMISSION INFORMATION

1. ADDRESS TO REQUEST APPLICATION PACKAGE

2. CONTENT AND FORM OF APPLICATION SUBMISSION

i. Project Abstract

ii. Project Narrative

iii. Budget

iv. Program-Specific Forms

v. Attachments

3. DUN AND BRADSTREET DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER TRANSITION

TO THE UNIQUE ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AWARD MANAGEM ENT (SAM)

4. SUBMISSION DATES AND TIM ES

5. INTERGOV ERNM ENTAL REVIEW

6. FUNDING RESTRICTIONS

V. APPLICATION REVIEW INFORMATION

1. REVIEW CRITERIA

2. REVIEW AND SELECTION PROCESS

3. ASSESSM ENT OF RISK

VI. AWARD ADMINISTRATION INFORMATION

1. AWARD NOTICES

2. ADMINISTRATIV E AND NATIONAL POLICY REQUIREM ENTS

3. REPORTING

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

APPENDIX A: EXPECTATIONS FOR RESEARCH AND EVALUATION ACTIVITIES

APPENDIX B: SPECIFIC GUIDANCE REGARDING CONTINUOUS QUALITY

IMPROVEMENT PLAN

APPENDIX C: PAY FOR OUTCOMES FEASIBILITY STUDIES

APPENDIX D: GLOSSARY OF SELECTED TERMS

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the fiscal year (FY) 2021 Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program – Formula grant. The purpose of this program is to support the delivery of coordinated and comprehensive high-quality and voluntary early childhood home visiting services to eligible families. The Health Resources and Services Administration (HRSA) administers this program in partnership with the Administration for Children and Families (ACF). Consistent with HRSA’s emphasis on innovation, collaboration, and effectiveness, the goals1 of the MIECHV Program are to: (1) strengthen and improve the programs and activities carried out under Title V of the Social Security Act; (2) improve coordination of services within at-risk communities; and (3) identify and provide comprehensive services to improve outcomes for eligible families2 living in at-risk communities.

Successful MIECHV Program recipients will achieve the following objectives:

1) Implement evidence-based home visiting models or promising approaches that:

a) Include voluntary home visiting3 as the primary service delivery strategy (See Appendix D for definitions of evidence-based home visiting models and promising approach home visiting models for the purposes of this notice of funding opportunity (NOFO));

b) Serve eligible families residing in at-risk communities, as identified in the current approved statewide needs assessment update;4 and

c) Target outcomes specified as statutorily mandated benchmark areas, which include: improved maternal and newborn health; prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits;

improvement in school readiness and achievement; reduction in crime or domestic violence; improvements in family economic self-sufficiency; and improvements in the coordination and referrals for other community resources and supports.5

2) Ensure the provision of high-quality home visiting services to eligible families living in at-risk communities by, in part, coordinating with comprehensive statewide early childhood systems to support the needs of those families.

3) Collaborate with state and local partners to increase the availability of and eligible families’ access to coordinated early childhood systems and high-quality services.

1 Social Security Act, Title V, § 511(a).

2 Under Social Security Act, Title V, § 511(k)(2), “[t]he term “eligible family” means— (A) a woman who is pregnant, and the father of the child if the father is available; or (B) a parent or primary caregiver of a child, including grandparents or other relatives of the child, and foster parents, who are serving as the child’s primary caregiver from birth to kindergarten entry, and including a noncustodial parent who has an ongoing relationship with, and at times provides physical care for, the child.”

3 Social Security Act, Title V, § 511(e)(7)(A).

4 Social Security Act, Title V, § 511(b).

5 Social Security Act, Title V, § 511(d)(1)(A).

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2. Background

Statutory Authority The MIECHV Program is authorized by 42 U.S.C. § 711(c) (Title V, § 511(c) of the Social Security Act) to make MIECHV grants to support the provision of home visiting services to eligible families by states, nonprofit organizations serving states, and U.S.

territories and jurisdictions. The Bipartisan Budget Act of 2018 (Pub. L. 115-123) (BBA), among other actions, extended appropriated funding for the MIECHV Program through FY 2022. In addition to reauthorizing the program, the BBA included new MIECHV provisions. Specifically, the BBA included a requirement that states conduct an updated statewide needs assessment, authority for use of funds for a Pay for Outcomes initiative, a requirement that HRSA develop data exchange standards, and a requirement that recipients demonstrate improvements in benchmark measures. This NOFO includes new requirements that reflect implementation of each of the provisions that were introduced through the BBA. The Consolidated Appropriations Act, 2021 (P.L.

116-260) (CAA), includes authority to use MIECHV grant funds during the declared COVID-19 public health emergency period, to:

A. Train home visitors in conducting virtual home visits (see Appendix D for a definition of virtual home visit) and in emergency preparedness and response planning for families;

B. Acquire the technological means as needed to conduct and support a virtual home visit for families enrolled in the program; and

C. Provide emergency supplies to families enrolled in the program, regardless of whether the provision of such supplies is within the scope of the approved program, such as diapers, formula, non-perishable food, water, hand soap, and hand sanitizer.

Overview Since 2010, the evidence-based MIECHV Program has been empowering families with the tools they need to thrive. The MIECHV Program supports home visiting for pregnant women and parents with children up to kindergarten entry living in at-risk communities.

Home visits by a nurse, social worker, early childhood educator, or other trained professional during pregnancy and early childhood improve the health and well-being of children and families. Through voluntary home visiting programs, trained professionals meet regularly in the homes of expectant parents or families with young children who want and ask for support, building strong, positive relationships. Home visitors serve an important function in partnering with families to assess their individualized strengths and needs, provide services tailored to those needs, screen for areas of specific risk, and assist with referrals and linkages to comprehensive services, as needed and appropriate. This facilitates not only access to coordinated care for participating families, but also more effective coordination and collaboration across service providers in the local early childhood system. Home visiting programs help prevent child abuse and neglect, support positive parenting, improve maternal and child health, and promote child development and school readiness.6 Evidence-based home visiting helps children and families get off to a better, healthier start, and it can be cost-effective in the long

6 U.S. Department of Health and Human Services, Administration for Children and Families, Home Visiting Evidence of Effectiveness (HomVEE).

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term, with the largest benefits coming through reducing the need for government spending on other programs, and increasing families’ earnings over time.7

States, territories, and nonprofit entities receive funding through the MIECHV Program, and have the flexibility to tailor the program to serve the specific needs of their communities. The MIECHV Program responds to the diverse needs of children and families living in at-risk communities, as identified through a needs assessment, that face disproportionate risks, challenges, and disparities. At-risk communities are defined in statute as communities with concentrations of the following indicators: premature birth, low-birth weight infants, and infant mortality, including infant death due to neglect, or other indicators of at-risk prenatal, maternal, newborn, or child health; poverty; crime;

domestic violence; high rates of high-school drop-outs; substance abuse8;

unemployment; or child maltreatment.9 (See Appendix D for a further definition of at risk communities). Throughout this NOFO, the terms “at-risk community” and “community”, except as otherwise noted, are intended to refer to communities with high concentrations of the indicators identified in statute. Home visiting programs aim to support these families and communities and advance health equity by leveraging individual family strengths, identifying and addressing the social determinants of health, and ensuring that children and families have equal opportunity to reach their fullest potential.

The MIECHV Program is an important part of a comprehensive statewide early childhood system (as defined in Appendix D) that supports pregnant women, parents and caregivers, and children from birth to kindergarten entry. Local implementing agency (LIA) staff serve as trusted partners that engage priority populations and bridge gaps between families and critical services and resources, both in the course of direct service provision and through community outreach and partnership. In addition, MIECHV recipients work with local, state, and national partners to identify and address systemic barriers to effective service access, coordination, and impact. These collaborations support program outcomes in the MIECHV benchmark areas and strengthen the broader early childhood system.

Finally, HRSA acknowledges that during the COVID-19 public health emergency, home visiting programs continue to play a vital role in addressing the needs of pregnant women, young children, and families, whether in-person or virtually. MIECHV recipients have achieved great success in sustaining service delivery and meeting families’ needs while minimizing service delivery interruptions when possible. As program implementation continues to be affected by the COVID-19 public health emergency, recipients are encouraged to communicate with HRSA about any impacts.

7 Michalopoulos, C, et. al. (2017). Evidence on the Long-Term Effects of Home Visiting Programs: Laying the Groundwork for Long-Term Follow-Up in the Mother and Infant Home Visiting Program Evaluation (MIHOPE). OPRE Report 2017-73. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services 8 “Substance abuse” is also known as “substance use disorder.”

9 Social Security Act, Title V, § 511(b)(1)(A).

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Program Requirements and Expectations This section describes key program requirements and expectations.

Outline of this Section:

A. Priority Population Recruitment and Enrollment

a. Priority for Serving High-Risk Populations

b. Enrollment

B. Requirements for New Applicants10 C. Implementing Evidence-Based Home Visiting Models

a. Selection of Home Visiting Service Delivery Model(s)

b. Fidelity to Home Visiting Service Delivery Model(s)

c. Model Enhancements

D. Systems Coordination

a. Early Childhood Systems Coordination and Collaboration

b. Written Agreements to Advance Coordination

E. Health Equity F. Implementation Oversight

a. High-Quality Supervision

b. Subrecipient Monitoring

c. HRSA Operational Site Visits

d. Home Visiting Budget Assistance Tool (HV-BAT)

e. Technical Assistance Engagement Expectations

G. Data and Evaluation

a. Data Exchange Standards for Improved Data Interoperability

b. State Evaluation – Promising Approaches

c. Coordinated State Evaluations – Evaluations of Other Recipient Activities

H. Pay for Outcomes I. Performance Reporting and Continuous Quality Improvement

a. Demonstration of Improvement

b. Continuous Quality Improvement

c. Performance Measurement Plan

A. Priority Population Recruitment and Enrollment

a. Priority for Serving High-Risk Populations As required by statute,11 recipients must give priority in providing services under the MIECHV Program to the following12:

• Eligible families who reside in communities in need of such services, as identified in the statewide needs assessment required under subsection 511(b)(1)(A), taking into account the staffing, community resources, and other requirements to operate at least one approved model of home visiting and demonstrate improvements for eligible families;

• Low-income eligible families;

10 Eligible entities not currently MIECHV grant recipients 11 Social Security Act, Title V, § 511(d)(4), as amended by the Bipartisan Budget Act of 2018, Title VI, § 50604, indicates the priority for serving high-risk populations.

12 Reporting defintions for these priority populations can be found in Form 1 – Demographic Performance Measures.

https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/performanceresources/attachment-a-form1-demographic-performance-measures.pdf https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/performanceresources/attachment-a-form1-demographic-performance-measures.pdf

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• Eligible families with pregnant women who have not attained age 21;

• Eligible families that have a history of child abuse or neglect or have had interactions with child welfare services;

• Eligible families that have a history of substance abuse or need substance abuse treatment;

• Eligible families that have users of tobacco products in the home;

• Eligible families that are or have children with low student achievement;

• Eligible families with children with developmental delays or disabilities; and

• Eligible families that include individuals who are serving or formerly served in the

Armed Forces, including such families that have members of the Armed Forces who have had multiple deployments outside of the United States.

b. Enrollment As required by statute, recipients must implement home visiting programs primarily through one or more selected evidence-based service delivery models.13 They must ensure fidelity to the model, which may include the development of policies and procedures to recruit, enroll, disengage, and re-enroll home visiting services participants. Enrollment policies should strive to balance continuity of services to eligible families over time with ensuring access to services for families who have not yet received services.

Recipients must develop and implement policies and procedures to avoid dual enrollment. Dual enrollment refers to home visiting participant enrollment and receipt of services through more than one MIECHV-supported home visiting model concurrently.

Recipients implementing more than one MIECHV-supported home visiting model, particularly in the same community, must, with fidelity to the model, develop policies and procedures to screen and enroll eligible families in the model that best meets their needs. Avoiding dual enrollment maximizes the availability of limited resources for home visiting services for eligible families and prevents duplicative collection and reporting of benchmark data.

Recipients may participate in or support the development of centralized intake systems (CIS) (see Appendix D for a definition of CIS) to reach and enroll eligible families, and avoid dual enrollment. CIS have the potential to improve families’ enrollment experiences, strengthen or streamline service referral processes, and facilitate early childhood systems coordination and collaboration.

B. Requirements for New Applicants

Instructions in this section are intended only for new applicants (i.e., eligible entities not currently MIECHV grant recipients) to meet the program requirements outlined in this NOFO. In addition to responding to all applicable requirements, new applicants are requested to submit a letter of intent to HRSA indicating the intent to apply for MIECHV funds through this NOFO, and a response to the requirements for new applicants outlined in Section IV. Letters of intent should be received no later than 7 calendar days

13 Social Security Act, Title V, § 511(d)(3).

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after the issuance/publication of this NOFO, or no later than March 25, 2021. See Section IV.7 for instructions for submitting the letter of intent.

HRSA expects that new applicants will leverage available TA resources provided by HRSA at the onset of the grant to identify immediate technical assistance needs related to the implementation of the grant and service delivery work plan. Additional TA resources are available on the MIECHV Program Technical Assistance webpage.

C. Implementing Evidence-Based Home Visiting Models

a. Selection of Home Visiting Service Delivery Model(s) As noted above, the MIECHV statute reserves the majority of funding for the delivery of services through implementation of one or more evidence-based home visiting service delivery models.14 Home visiting service delivery models meeting U.S. Department of Health and Human Services (HHS)-established criteria for evidence of effectiveness and eligible for implementation under MIECHV have been identified.15 Per statute, recipients may expend no more than 25 percent of the grant awarded for a fiscal year for conducting and evaluating a program using a service delivery model that qualifies as a promising approach.16 The MIECHV statute defines a home visiting service delivery model that qualifies as a promising approach; see Appendix D for the definition of a promising approach.17

When selecting a model or multiple models, recipients should ensure the selection can:

1) Meet the needs of the state’s, territory’s, or jurisdiction’s at-risk communities as identified in the current approved statewide needs assessment update and the state’s, territory’s, or jurisdiction’s targeted priority populations named in statute;

2) Provide the best opportunity to accurately measure and achieve meaningful outcomes in MIECHV benchmark areas and performance measures;

3) Be implemented effectively with fidelity to the model in the state, territory, or jurisdiction based on available resources and support from the model developer;

and

4) Be well matched for the needs of the state’s, territory’s, or jurisdiction’s early childhood system.

Recipients may select multiple models for different communities to support a continuum of home visiting services that meet families’ specific needs. Additionally, as families’ goals and needs change over time, recipients may transition families with their consent from one model to another.

14 Social Security Act, Title V, § 511(d)(3)(A) identifies various specific criteria applicable to such evidence-based home visiting models.

15 See Section VIII for a list of evidence-based home visiting models eligible for implementation under MIECHV that meet the HHS-established criteria for evidence of effectiveness.

16 Social Security Act, Title V, § 511(d)(3)(A).

17 Social Security Act, Title V, § 511(d)(3)(A)(i)(II).

https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/miechv-program-ta

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b. Fidelity to Home Visiting Service Delivery Model(s) Recipients must have policies and procedures in place to ensure fidelity of implementation to the evidence-based home visiting service delivery model(s) they select (refer to Appendix D for a definition of fidelity). Policies and procedures should include review and submission of fidelity information to home visiting model developers.

Any recipient implementing a home visiting service delivery model that qualifies as a promising approach must also implement the model with fidelity. Fidelity requirements include all aspects of initiating and implementing a home visiting model, including, but not limited to:

• Recruiting and retaining families;

• Providing initial and ongoing training, supervision, and professional development for staff;

• Establishing an information management system to track data related to fidelity and service delivery; and

• Developing a resource and referral network to support families’ needs.

Changes to an evidence-based model that alter the core components related to program outcomes are not permissible, as they could impair fidelity and undermine the program’s effectiveness.

c. Model Enhancements For the purposes of the MIECHV Program, an acceptable enhancement of an evidence-based model is a variation to better meet the needs of at-risk communities or certain eligible families that does not alter the model’s core components, as defined by the model. Model enhancements may or may not have been developed by the national model developer, and enhancements may or may not have been tested with rigorous impact research. Prior to implementation, the model developer must determine that the model enhancement does not alter the core components related to program impacts, and HRSA must determine it to be aligned with MIECHV Program activities and expectations. Recipients that wish to adopt enhancements to a model must submit documentation of concurrence that the enhancement does not alter core components related to program impacts from the national model developer(s) and receive approval from HRSA. See further instructions in Section IV.

Note: Temporary changes to the model made by the model developer due to an emergency are not model enhancements.

D. Systems Coordination

a. Early Childhood Systems Coordination and Collaboration Per the MIECHV statute, recipients must ensure the provision of high-quality home visiting services to eligible families in at-risk communities by, in part, coordinating with comprehensive statewide early childhood systems to support the needs of those families.18 To do this, recipients must establish appropriate linkages and referral networks to other community resources and supports.19 Refer to Appendix D for a list of potential early childhood systems partners. Additional examples of effective systems

18 Social Security Act, Title V, § 511(b)(1)(B).

19 Social Security Act, Title V, § 511(d)(3)(B).

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coordination and collaboration strategies include working with state and local partners to: increase the availability of and access to a continuum of two-generation early childhood services; coordinate programs, services, and data collection and reporting systems to reduce gaps and inefficiencies; align activities and leverage partnerships to engage priority populations in services and improve shared outcomes; identify and facilitate meaningful changes in structural barriers to eliminate health disparities; and engage families and other community representatives as leaders and partners toward shared decision-making and improved health equity.

Examples of early childhood systems coordination and collaboration initiatives to improve family outcomes in the MIECHV benchmark areas include:

• Educating pregnant women and parents on the benefits of breastfeeding, safe sleep practices, and healthy physical activity of children, highlighting the importance of prenatal, postpartum, and well-child visits and facilitating access to health coverage and care, and participating in referral partnerships with child nutrition programs such as the state’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

• Improving service access and other supports for family needs related to behavioral health (e.g., opioid or other substance use, neonatal abstinence syndrome, caregiver depression, children’s social-emotional health and development). This may include the use of mental health consultation services to increase programs’ capacity.

• Educating caregivers about the risks, impacts, and interventions associated with intimate partner violence (IPV), and facilitating connections to quality services.

• Preventing or mitigating the effects of child maltreatment by assessing families’ strengths and needs, providing education on safe and effective parenting strategies and enhancing parent-child relationships, making referrals to necessary family support services, and partnering with child welfare agencies and family-serving court programs to engage families in voluntary home visiting services.

• Addressing critical social determinants of health, including families’ housing quality and stability, and promoting caregivers’ access to education and employment opportunities and other economic supports to improve family self-sufficiency.

• Identifying and working to implement policy and practice changes that would increase access to home visiting services and referrals for families through partnerships with health care providers and payers (e.g., Medicaid, Children’s Health Insurance Program, private insurers), and/or strengthening partnerships with families’ health care providers to reduce duplicative screenings and promote family health.

Recipients should develop policies and procedures, in collaboration with other home visiting and early childhood partners, to ensure sustained services and smooth transitions across a continuum of home visiting and early childhood services for eligible families from pregnancy through kindergarten entry, in alignment with model fidelity requirements.

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Other state and local advisory groups also serve an important function in guiding MIECHV project planning, implementation, and/or evaluation. Recipients must ensure involvement in project planning, implementation, and/or evaluation by at least one statewide early childhood systems advisory committee or coordinating entity (e.g., Early Childhood Advisory Council, Governor’s Children’s Cabinet, Individuals with Disabilities Education Act (IDEA) Part C Interagency Coordinating Council, State Advisory Council on Early Childhood Education and Care).

To strengthen coordination with comprehensive statewide early childhood systems and improve service delivery quality, HRSA encourages MIECHV recipients to engage in active, ongoing collaboration with the following representatives, including participation in any MIECHV advisory groups (if such a group exists), whenever feasible:

• Representatives of aligned early childhood programs (including the Early Childhood Comprehensive Systems (ECCS) funding recipient, where applicable;

see also Appendix D);

• Tribal representatives; and

• Individuals representing eligible families and communities served.

MIECHV recipients may also engage and provide support for representatives to participate equitably and meaningfully in these roles and ensure that advisory members represent the diversity of the populations being served.

b. Written Agreements to Advance Coordination Recipients must ensure the involvement of representatives from key state agencies in project planning, implementation, and/or evaluation through the development and implementation of signed written agreements, such as letters of agreement (LOAs) or memoranda of understanding (MOUs). These agreements may address state and local partnerships to facilitate referrals, screening, follow-up, and service coordination, as well as systems and data coordination (e.g., data sharing and data exchange standards), as applicable to each partner’s scope. To the extent possible, recipients should address expectations for coordination among local subrecipients of signing state agencies.

Recipients must develop agreements with:

• The state’s ECCS recipient, if there is one;

• The state’s Maternal and Child Health Services (Title V) agency;

• The state’s Public Health agency, if this agency is not also administering the state’s Title V program;

• The state’s agency for Title II of CAPTA;

• The state’s child welfare agency (Title IV-E and IV-B), if this agency is not also administering Title II of CAPTA;

• The state’s IDEA Part C and Part B Section 619 lead agency(ies); and

• The state’s Elementary and Secondary Education Act Title I or state pre-kindergarten program.

HRSA requires recipients to review, and update as appropriate, agreements at least every 3 years (i.e., those established and dated before October 1, 2018). Recipients must submit all current agreements with the required partners listed above to HRSA by September 30, 2021. The agreements are not required for submission with this

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application. (Note: HRSA intends for these agreements to outline the expectations of collaborators and support effective collaboration. These are not required to be legally binding documents.) HRSA also encourages alignment of agreements with relevant state-level early childhood action plans or stated goals of statewide early childhood systems entities.

In addition, HRSA encourages recipients to identify and collaborate with other high-priority partners, including including state Medicaid agencies, those implementing the Family First Prevention Services Act20 and Preschool Development Grants. Recipients may wish to develop written agreements that clearly state the purpose of the collaboration, establish a shared vision and goals, and outline key roles of each partner to achieve shared goals.

E. Health Equity

In alignment with HRSA’s strategic goal to achieve health equity and enhance population health and the Biden-Harris Administration’s commitment to a whole-of-government equity approach, HRSA recommends recipients implement home visiting program strategies that contribute to equitable improvements and reduce disparities in family outcomes in MIECHV benchmark areas. As a way to promote and advance health equity, recipients may wish to consider the role of home visiting services and coordination with comprehensive statewide and local early childhood systems in identifying and addressing health disparities in their project planning, implementation, and/or evaluation and to propose specific activities to further define, support, or evaluate those efforts. Home visiting implementation strategies that may advance health equity include:

• Collecting and analyzing program data to identify key health disparities and the root causes of inequity;

• Recruiting and retaining a diverse workforce representative of communities served;

• Leveraging Continuous Quality Improvement (CQI) activities to identify, address, and mitigate systemic barriers;

• Engaging family and community representatives in advisory and collaborative roles;

• Providing leadership development opportunities for families and family representatives; and

• Promoting comprehensive and multi-generational approaches to service delivery and coordination.

F. Implementation Oversight

a. High-Quality Supervision Recipients must maintain high-quality supervision21 to establish home visitor competencies. HRSA encourages the use of reflective supervision or practices aligned with infant early childhood mental health consultation (IECMHC), consistent with model

20 P.L. 115-123, Division E, Title VII 21 Social Security Act, Title V, § 511(d)(3)(B)(iii).

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fidelity, for home visiting staff funded through the MIECHV grant as components of high-quality supervision. (Refer to Appendix D for a definition of reflective supervision and IECMHC.) Recipients and LIAs should develop and implement policies and procedures that ensure high-quality supervision in alignment with fidelity to the model(s) implemented.

b. Subrecipient Monitoring Recipients must monitor subrecipient performance for compliance with federal requirements and performance expectations, including timely Federal Funding Accountability and Transparency Act (FFATA) reporting. (For additional information regarding Subrecipient Monitoring and Management, see Uniform Administrative Requirements (UAR) 45 CFR part 75 and the Subrecipient Monitoring Manual for MIECHV Award Recipients. This requirement applies to all subrecipients, including those that oversee LIAs (i.e., intermediaries). For additional information about FFATA reporting, see Section IV.)

Recipients must effectively manage all subrecipients of MIECHV funding to ensure successful performance of the MIECHV Program and to ensure compliance with fiscal, administrative, and program requirements. Monitoring activities must ensure subrecipients comply with applicable requirements outlined in the UAR, and MIECHV statutory and programmatic requirements.22 Recipients must also execute subrecipient agreements that incorporate all of the elements of 45 CFR § 75.351–353 and, either expressly or by reference, the subrecipient monitoring plan developed by the recipient.

Recipients must be able to determine if costs proposed and subsequently incurred by subrecipients are allowable/unallowable. Recipients must base their final determinations on allowability of costs on their documented organizational policies and procedures.

Recipients must develop and execute a subrecipient monitoring plan that outlines MIECHV program requirements and performance expectations, and a process to assess subrecipients’ implementation of these requirements. The subrecipient monitoring plan must include an evaluation of each subrecipient's risk of noncompliance, identify the person(s) responsible for each monitoring activity, and include timelines for completion for each monitoring activity. Recipients must design their subrecipient monitoring activities to ensure that the subaward:

• Is used for authorized purposes;

• Is used for allowable, allocable, and reasonable costs;

• Is in compliance with federal statutes and regulations;

• Is in compliance with the terms and conditions of the subaward; and

• Achieves applicable performance goals.

Subrecipient monitoring plans must include provisions for:

• Review of financial and performance reports as required by the recipient in compliance with federal requirements;

• Performing site visits to review financial and program operations;

• Providing technical assistance, when needed;

22 Social Security Act, Title V, § 511(d).

https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75 https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/srm-manual-august-2018.pdf https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/srm-manual-august-2018.pdf https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75#sg45.1.75_1344_675_1350.sg4

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• Follow-up procedures to ensure timely and appropriate action by the subrecipient on all deficiencies identified through required audits, site visits, or other procedures pertaining to the federal award; and

• Issuance of a management decision for audit findings (as applicable) pertaining to the federal award provided to the subrecipient as required by 45 CFR § 75.521.

c. HRSA Operational Site Visits HRSA conducts operational site visits with MIECHV recipients approximately every 3 years to assess recipient compliance with MIECHV statutory and programmatic requirements. Pursuant to 45 CFR § 75.364, HRSA and its designees must have the right of access to any books, documents, papers, or other records that are pertinent to the awards in order to make audits, examinations, excerpts, transcripts, and copies of such documents. This right also includes timely and reasonable access to a recipient’s personnel for the purpose of interview and discussion related to such documents.

Timely access is defined as a recipient’s response to all document requests and requests to meet with a recipient’s personnel by the deadlines stated by HRSA or its designees.

d. Home Visiting Budget Assistance Tool (HV-BAT) The Home Visiting Budget Assistance Tool (HV-BAT) is an Excel-based instrument that collects information on standardized cost metrics from programs that deliver home visiting services. The HV-BAT is designed for use by MIECHV-funded LIAs and recipients to collect and report comprehensive home visiting program costs incurred by LIAs during a 12-month period. It may help MIECHV recipients and LIAs in several ways, including program monitoring, budget planning, economic evaluation, and leveraging innovative financing strategies (technical assistance resources are available on the MIECHV Data, Evaluation, and Continuous Quality Improvement webpage).

Beginning with the FY 2021 period of performance, HRSA will require reporting of HV- BAT data for one-third of recipients each year, resulting in collection of data from all recipients over a 3-year time period. HRSA is requiring this data collection in order to:

• Support recipients in using empirical cost data to inform program planning, budgeting, and subrecipient monitoring;

• Conduct descriptive research assessing the variability of implementation costs across MIECHV-funded home visiting programs; and

• Inform future activities to support policy priorities related to public financing of home visiting services and PFO approaches.

HRSA will provide specific reporting instructions, including lists of which recipients will report each year, associated timelines, and submission requirements, after the start of the period of performance. Additional resources to support recipients in utilizing the HV- BAT and cost data are available in technical assistance resources on the HRSA website at the MIECHV Data, Evaluation, and Continuous Quality Improvement webpage.

e. Technical Assistance Engagement Expectations The MIECHV Program’s technical assistance (TA) system supports recipients’ efforts to improve family outcomes and strengthen the proficiency of state and local early https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75#se45.1.75_1521 https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75#se45.1.75_1521 https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.75#se45.1.75_1364 https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/home-visiting-program-technical-assistance/performance-reporting-and-evaluation-resources https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/home-visiting-program-technical-assistance/performance-reporting-and-evaluation-resources

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childhood systems leaders and practitioners.23 For a description of what the TA system supports, please see the MIECHV Program Technical Assistance webpage.

MIECHV promotes the provision of TA through a relationship-based approach. As such, HRSA expects recipients to engage with TA providers to support improvement in high-quality implementation of home visiting in their state, territory, or jurisdiction. Recipients should regularly engage TA providers as partners to help achieve short-and long-term goals. At least once annually, recipients must work with their TA providers to assess their TA priorities and develop a plan to address those priorities. Recipients must also engage with their TA providers during the review of annual performance reports and CQI plans.

G. Data and Evaluation

a. Data Exchange Standards for Improved Data Interoperability Section 50606 of the Bipartisan Budget Act of 2018 provides new authority for HRSA to establish data exchange standards for improved interoperability in two categories of information: (1) data required to be submitted as part of federal data reporting, and (2) data required to be electronically exchanged between the MIECHV state agency and other agencies within the state by required by applicable federal law.24

HRSA encourages recipients to consider approaches and plans to facilitate improved data interoperability in their state, territory, or jurisdiction through activities such as data exchange standards creation or adoption, data sharing, or data coordination with other state agencies or early childhood programs. These plans may range in scope and content, depending on capacity and readiness, among other factors, and focus on state and/or local operations.

Note that no changes to existing MIECHV federal data reporting are required due to this new authority. In addition, HRSA is not issuing new requirements around the adoption of data exchange standards at this time.

More information on implementing data exchange standards is available on the HRSA the MIECHV Data, Evaluation, and Continuous Quality Improvement webpage.

b. State Evaluation – Promising Approaches Recipients that propose to implement a home visiting model that qualifies as a promising approach are required to conduct a rigorous evaluation of that approach.25 The purpose of such an evaluation is to contribute to the evidence that may help support meeting HHS’ criteria of effectiveness for the promising approach. Recipients must evaluate all new or continuing promising approaches implemented in FY 2021.

Recipients must design such evaluations for an assessment of impact using an appropriate comparison condition and meet expectations of rigor outlined in Appendix A. (Refer to Appendix D for complete definition of a promising approach.) Recipients may propose to continue an existing evaluation of a promising approach implemented

23 Social Security Act, Title V, § 511(c)(5).

24 Social Security Act, Title V, § 511(h)(5).

25 Social Security Act, Title V, § 511(d)(3)(A)(i)(II).

https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/miechv-program-ta https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting/home-visiting-program-technical-assistance/performance-reporting-and-evaluation-resources

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through prior MIECHV awards in order to meet the requirements of this section. For new promising approach evaluations, an evaluation plan describing the technical details of the evaluation is due to HRSA no later than 120 days from the project start date. For continuing promising approach evaluations, a modified evaluation plan and timeline noting any significant changes to the evaluation is due to HRSA no later than 120 days from the project start date. Further guidance and TA will be available after HRSA issues the award.

c. Coordinated State Evaluations – Evaluations of Other Recipient Activities Recipients are not required to conduct an evaluation of their home visiting programs, unless they implement a promising approach, or a pay for outcome (PFO) initiative.

However, HRSA encourages recipients to conduct evaluations of their programs by participating in the coordinated state evaluation (CSE).

In order to continue to support well-designed, rigorous evaluation that contributes to the field of home visiting and addresses topics of high priority in the MIECHV Program, HRSA has established a coordinated approach for state evaluations. If recipients intend to conduct a state evaluation with their MIECHV FY 2021 award, they must participate in the CSE. The purpose of this evaluation approach is to contribute to advances in knowledge of early childhood home visiting services through coordinated effort among MIECHV recipients. Recipients that propose to conduct evaluations through this funding opportunity must conduct an evaluation reflective of their interests within a defined priority topic area in coordination with other recipients and with TA support from a national evaluation coordinating center. The requirements for a CSE do not apply to promising approach or PFO initiative evaluations.

The goals of the CSE approach include:

• Aligned evaluation designs across recipients;

• Aligned measurement strategies across recipients;

• Shared learning and collective impact across recipients;

• Pooling or sharing of evaluation data across recipients, as appropriate and feasible; and

• The ability to generalize and compare evaluation findings across recipients.

In order to achieve these goals, the CSE approach has several distinct components:

1) Priority topics: Through stakeholder engagement, HRSA has identified four topic areas that reflect priority evaluation topics in the field and MIECHV Program priorities. Through this funding opportunity, recipients may only request funds for CSE in these topic areas. Recipients that propose to conduct a CSE shall select one of the following four topic areas:

(a) Family engagement and health equity. In particular, HRSA encourages evaluations that build upon and move beyond existing work on family retention, with particular focus on health equity. Such evaluations might evaluate the alignment between family needs and expectations for home visiting, and the success of family goal-setting, planning, and attainment as antecedents to family retention.

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(b) Workforce development. In particular, HRSA encourages evaluations of workforce development that address home visitor professional well-being as an antecedent to staff retention.

(c) Maternal health. In particular, HRSA encourages evaluations that address maternal and other primary caregiver mental health and home visiting supports for families affected by substance use.

(d) Implementation quality/Fidelity. In particular, HRSA encourages evaluations that address virtual service delivery, building upon and moving beyond the feasibility and acceptability of such approaches.

Such evaluations might evaluate the quality, content, and effectiveness of virtual service delivery of home visiting programs.

Based on these preferences, HRSA will form peer networks among recipients and, as needed, the recipients will invite their contracted evaluators to peer network meetings. Post award, peer networks will coordinate their evaluation activities with TA support from the MIECHV Evaluation Coordinating Center

(MECC).

In addition to identifying topic areas of interest, recipients and their peer networks should consider how precision home visiting methods and a health equity framework may be applied to their evaluation designs and evaluation questions.

Precision home visiting research methods focus on the components of home visiting services rather than on complex models of home visiting that are administered uniformly.