Family Home Visiting Forms Guidance 2015

Family Home Visiting Forms Guidance 2015 Family Home Visiting Unit Maternal & Child Health Section Community & Family Health Division Minnesota Department of Health address: P.O. Box 64882, St. Paul, MN 55164 phone: 651-201-3760 email: health.fhvdata@state.mn.us web: www.health.state.mn.us/divs/cfh/program/fhv 1

Table of Contents Contents Family Home Visiting Forms Guidance 2015... 1 Table of Contents... 2 Completing FHV Evaluation Forms: What to Report... 4 Required Forms... 4 How to fill out forms... 5 Who to Direct Questions to... 5 Caregiver Intake... 6 Child Intake... 11 Primary Caregiver Closure... 44 Appendix... 46 Terms and Acronyms... 46 Reporting for the 2015 FHV Evaluation... 47 What to Submit... 47 Which Forms to Complete... 48 Where to submit... 49 When to Submit... 49 Collection of Name & Address Identifiers... 50 2015 FHV Evaluation: Data to Report to the MDH... 51 List of Validated Screening and Assessment Tools Used in Family Home Visiting (FHV) Evaluation. 52 Maternal Depression Screening Algorithm Edinburgh Postnatal Depression Scale (EPDS)... 53 Maternal Depression Screening Algorithm PHQ-9... 55 Crisis Intervention Algorithm... 57 What is Next? Positive Screen for Depression... 58 What does a positive screen mean?... 58 FHV MN State Statute... 61 Subdivision 1. Establishment; goals.... 61 Subd. 2.... 61 Subd. 3.Requirements for programs; process.... 61 2

Subd. 4.Training.... 63 Subd. 4a... 64 Subd. 5.... 64 Subd. 6.... 64 Subd. 7.... 65 Subd. 8.... 65 Subd. 9.... 65 TANF Grant Guidelines... 66 Eligible Program Services... 66 Eligible Populations... 67 Determination and Documentation of Eligibility for Family Home Visiting or WIC Clinic Services... 67 Matching Requirement... 72 Program and Administrative Costs... 73 Reporting Requirements... 73 3

Completing FHV Evaluation Forms: What to Report Per Statute M.S. 145A.17, Family Home Visiting (FHV) data reported to the Minnesota Department of Health (MDH) is intended to measure the impact of services provided to families. Local public health home visiting programs provide a variety of services to maternal and child health clients. When determining what data to collect and report to MDH as part of the FHV evaluation, please refer to the statute (on page 61) as well as the document, 2015 Family Home Visiting Evaluation: Data to Report to the Minnesota Department of Health (on page 51), both included in the appendix. Local public health home visiting programs utilize a variety of funding sources for different types of home visiting. If TANF funds are used for home visiting, those TANF-funded activities must reflect the goals of the statute and must be reported to MDH as part of the FHV state evaluation. The FHV evaluation is comprised of a limited set of variables not intended to capture all best practices in local FHV programs. Evaluation variables and questions should not serve as a substitute for the broader range of evidence-based family home visiting best practices implemented in local programs. For directions on how to report for 2015, please refer to the document, Reporting for the 2015 FHV Evaluation also in the appendix on page 47. Required Forms Regardless of FHV Model, all Caregiver-child dyads require a Caregiver Intake, and eventually a Child Intake and Closure form. For clients enrolled in NFP, HFA, or long term, ongoing FHV models additional forms are required depending on whether the appropriate age interval for the dyad is reached. Clients enrolled in short-term/limited FHV will only need to do the additional forms if the visit(s) fall within the age interval for a form. All forms, from Caregiver Intake to Closure, must be filled out for each child. In addition, clients will need a new Caregiver & Child Intake form for the following situations: - Caregiver-Child dyad changes FHV model - Caregiver-Child dyad moves to another local health department s jurisdiction (i.e. changes Site) - Caregiver changes for a child - Caregiver-Child dyad restarts an FHV program for which they have already had a closure form filled out. For clients enrolled in NFP, HFA, or other, ongoing FHV services, all FHV evaluation forms are completed for the time frame that the client/child received those services. Data should be collected within two months before or two months after the specified interval. For example, home visitors can complete the six month form two months before the child s sixth month birthday until two months after the child s sixth month birthday. Exceptions are the two intake forms. Also, consider the appropriate age 4

of the child as required by the screening tools such as the ASQ-3 and the ASQ:SE. If a child s age is too young or too old to administer a particular tool during the interval specified in the evaluation form, please still report data for the rest of the form if the visit is within the two months before or two months after the specified interval. For caregivers & children enrolled in NFP, the LPH agencies should complete all forms required by the NFP model. IN ADDITION, the NFP Supplemental forms should be completed in ETO when the Caregiver/Child reaches the appropriate interval. How to fill out forms For dyads enrolled in HFA, NFP, or Other, Ongoing FHV, MDH expects that all questions in the 2015 FHV Evaluation be answered if applicable. Short-term/limited dyads may not be required to answer all the questions of the 2015 FHV Evaluation, but MDH expects the answers to be reported if the home visitor does collect the data as part of their FHV intervention. For ease of use, required questions for shortterm/limited dyads are marked with an asterisk (*) on the 2015 FHV Evaluation forms. Answering a question Home visitors should fill out every question that they can in the way the form asks. When the home visitor can t answer the question or doesn t know the answer, leave it blank. o Some questions have 88 Client does not know/not sure or 99 Client declines to answer, which are not the same as a blank. Don t create new categories. The Family Home Visiting Reporting and Evaluation System (FHVRES) will only accept values that are on the forms. MDH will not evaluate notes in comments sections. FHVRES also does not accept comments. Sites implementing Nurse-Family Partnership should follow NFP guidance on how to fill out forms. Differences among sites Different sites have different processes for physically filling out paper and electronic forms. Refer questions about this process to your local supervisor or to your data system vendor. If your site does not have a data system, contact Health.FHVdata@state.mn.us to get the correct electronic forms. Who to Direct Questions to Nurse Consultants: Questions related to home visiting practice Data System Vendors: Questions related to how your data system functions MDH Evaluation Team: Questions related to the evaluation and data submissions o Health.FHVdata@state.mn.us 5

Caregiver Intake Caregiver Intake When to fill out a caregiver Intake? Client s first home visit Question in the forms Additional guidance 1 Data entry staff (name) The person doing the data entry into your system. This field allows sites to filter data reports by staff. MDH won t use this information for other purposes. 2 Home visitor (name) This field allows sites to filter data reports by staff. MDH won t use this information for other purposes. 3 Site The health department site (county or city) where the client lives. 3b Name of subcontracting agency, if applicable Only fill this out if there is a subcontracting agency performing family home visiting. If there is a new subcontracting agency that doesn t appear on this list, contact Health.FHVdata@state.mn.us 4 Date of first home visit For ongoing home visiting: This field should be the date of the first home visit after the client has been determined to be eligible and has been enrolled in home visiting. For example, do not record the date of the Parent Survey. For short-term/limited home visiting: This date can be when the client is assessed. For more information, see appendix: 2015 FHV Evaluation: Data to Report to the MDH on page 51 5 There is no #5. MDH will fix this in future versions. 6 First name 7a Last name 7b Maiden name, if applicable Any previous legal last name. Collected for use in deduplication of FHV data 8a Identifier #1 8b Identifier #2 CaregiverID Optional field that local health departments and data systems may use as an additional identifier. MDH won t use this information for other purposes. 9 Home address (number and street or If homeless, write "homeless" in the address field. rural route) 10 City 11 State 12 Zip 13 Birth date 14 Home visiting model To better understand the difference between long term vs short term home visiting, see appendix: FHV Evaluation Data to Report to the MDH on page 51 6

Caregiver Intake Question in the forms Additional guidance 15 Funding source This question is intended to differentiate MIECHV vs non- MIECHV funded services. 16 Client type at enrollment Postpartum mother (biological) is for any biological (relationship to index child) mother who is not pregnant. 17 Gender 18 PRENATAL/POSTPARTUM ONLY: How many live births have you had? If the primary caregiver is the biological mother of the index child (born or unborn), how many live births did she have before the index child? Do not count the index child. 19 Hispanic or Latino/a ethnicity The responses regarding ethnicity and race should reflect what the person considers herself/himself to be and are not based on percentages of ancestry. Hispanic origin can be viewed as the heritage, nationality group, lineage, or country of birth of the person or the person s parents or ancestors before their arrival in the United States. People who identify their origin as Hispanic, Latino, or Spanish may be any race. 20 Race (select one or more) The responses regarding ethnicity and race should reflect what the person considers herself/himself to be and are not based on percentages of ancestry. If home visitor selects other for this question, they must specify. Do not specify multiracial or biracial. If a client is more than one race, select each appropriate race. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American A person having origins in any of the Black racial groups of Africa. American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 21 Primary language The language that is used in the home most of the time 7

Caregiver Intake Question in the forms Additional guidance 22 Legal marital status Select "01 Married" if the client is legally married in the United States 23 PRENATAL CLIENTS ONLY: How many weeks pregnant are you (client) now? Note the categories provided for marital status. Do not create additional categories such as single, living together, etc. Weeks pregnant at date of first home visit (refer to #4). Round down to the nearest week. 24 In the past 6 months, have you (client) obtained care at the emergency room/urgent care center for ANY reason? If the mother was not enrolled prenatally, leave this blank. FHVRES will reject an answer of 0. It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you obtained care 25 Are you (client) currently working? No, Not employed indicates that the person is not working for pay (this category may include, for example, students, homemakers and those actively seeking work but currently not employed). 26 What is your (client's) household size? Someone who receives disability and is not currently working is No, not employed. Disability income is counted in household income question. A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. A pregnant woman should be counted as two, taking into consideration the unborn fetus(es). 27 Do any members of your (client's) household currently serve in the Armed Forces (active or reserve)? Household size: total number of individuals sharing income and consumption of goods and/or services. A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. Household size: total number of individuals sharing income and consumption of goods and/or services. 8

Caregiver Intake Question in the forms 28 Which category best describes your (client's) total annual household income and benefits? Additional guidance A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. Household size: total number of individuals sharing income and consumption of goods and/or services. "Income and benefits" should include annual earnings from work rent from tenants/borders cash assistance from friends/relatives child support payments TANF MFIP/Cash Grant Social Security (SSI/SSDI/OAI) Unemployment Insurance) Consider calculating household income in a similar way you might be determining eligibility for other services like MCH or TANF. 29 In what educational program are you (client) currently enrolled, if any? 30 What is the highest level of education you (client) have attained? 31 In the past 6 months, have you (client) completed any educational programs or classes, such as grade advancement, certificate, ESOL, etc.? 32 Do you (client) have health insurance? Annual income data can be estimated from monthly data (monthly income x 12). ESOL = English for Speakers of Other Languages, also sometimes referred to as English as a Second Language (ESL) or English as a New Language (ENL) It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you completed any 02 No, uninsured Includes clients who have applied for insurance (pending) Home visitors who encounter caregivers who do not have health insurance coverage are encouraged to use MNsure.org for coverage options available in Minnesota state. 9

Caregiver Intake Question in the forms 33 What is your major medical care resource for health insurance? (select one or more) Additional guidance 02 Public insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning Program 10

Child Intake Child Intake When to fill out child intake? Caregivers enrolled prenatally: fill out child intake at first postpartum visit Caregivers enrolled after child s birth: fill out child intake at the first visit usually the same visit as the caregiver intake Question in the forms Additional guidance 1 Data entry staff (name) The person doing the data entry into your system. 2 Home visitor (name) 3 Site The health department site (county or city) where the client lives. 3b Name of subcontracting agency, if applicable Only fill this out if there is a subcontracting agency performing family home visiting. If there is a new subcontracting agency that doesn t appear on this list, contact Health.FHVdata@state.mn.us 4 Date of home visit 5 Total # home visits to-date Include the total number of visits with the caregiver, including the current visit and any previous FHV visits related to the current child. 6 First name (child) 7 Last name (child) 8a Identifier #1 (child) 8b Identifier #2 (child) ChildID Optional field that local health departments and data systems may use as an additional identifier. MDH won t use this information for other purposes. 9 Primary caregiver ID CaregiverID 10 Birth date (child) Please double check this field for accuracy. It s very important for many evaluation measures, and difficult for FHVRES to catch mistakes. 11 Gender Child s gender 11

Child Intake Question in the forms Additional guidance 12 Hispanic or Latino/a ethnicity Child s ethnicity The responses regarding ethnicity and race should reflect what the person considers their child to be and are not based on percentages of ancestry. Hispanic origin can be viewed as the heritage, nationality group, lineage, or country of birth of the person or the person s parents or ancestors before their arrival in the United States. People who identify their origin as Hispanic, Latino, or Spanish may be any race. 13 Race (child) (select one or more) The responses regarding ethnicity and race should reflect what the person considers their child to be and are not based on percentages of ancestry. If home visitor selects other for this question, they must specify. Do not specify multiracial or biracial. If a client is more than one race, select each appropriate race. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American A person having origins in any of the Black racial groups of Africa. American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 12

Child Intake Question in the forms 14 BIOLOGICAL MOTHERS ONLY: Did you (client) smoke cigarettes at all during pregnancy, including before you found out you were pregnant? 15 ANSWER ONLY IF ENROLLED PRENATALLY: Since enrollment, have you (client) obtained care at the emergency room/urgent care center for ANY reason? 16 ANSWER ONLY IF ENROLLED PRENATALLY: Since enrollment, have you (client) completed any educational programs or classes, such as grade advancement, certificate, ESOL, etc.? 17 ANSWER ONLY IF ENROLLED PRENATALLY: Do you (client) have health insurance? Additional guidance This includes electronic cigarettes (e-cigs). ESOL = English for Speakers of Other Languages, also sometimes referred to as English as a Second Language (ESL) or English as a New Language (ENL) 02 No, uninsured Includes clients who have applied for insurance (pending) 18 ANSWER ONLY IF ENROLLED PRENATALLY: What is your major medical care resource for health insurance? (select one or more) Home visitors who encounter caregivers who do not have health insurance coverage are encouraged to use MNsure.org for coverage options available in Minnesota state. Caregiver s major medical care resource 02 Public insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning Program 19 Does your child have health insurance? 02 No, uninsured Includes clients who have applied for insurance (pending) 20 What is your child's major medical care resource for health insurance? (select one or more) 02 Public insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning Program 13

6 Months Infant Fill out 6 months infant form when child is 4 months 0 days to 7 months 30 days Questions with more specific time requirements #10 depression screening: screened by 3 months postpartum, reported on 6 months form #25 NCAST: assessed by 3 months postpartum, reported on 6 months form #26 - #29 ASQ-3 (4 months questionnaire): follow ASQ guidance for when to complete #30 domestic violence screening: screened by 3 months postpartum, reported on 6 months form Question in the forms Additional guidance 1 Data entry staff (name) The person doing the data entry into your system. 2 Home visitor (name) 3 Site The health department site (county or city) where the client lives. 3b Name of subcontracting agency, if applicable Only fill this out if there is a subcontracting agency performing family home visiting. If there is a new subcontracting agency that doesn t appear on this list, contact Health.FHVdata@state.mn.us 4 Date of home visit 5 Total # home visits to-date Include the total number of visits with the caregiver, including the current visit and any previous FHV visits related to the current child. 6 Child ID 7 Primary caregiver ID 8 Legal marital status Select "01 Married" if the client is legally married in the United States 9 BIOLOGICAL MOTHERS ONLY: Are you (client) taking a vitamin containing folic acid? Note the categories provided. Do not create additional categories such as single, living together, etc. 14

6 Months Infant Question in the forms 10 BIOLOGICAL MOTHERS ONLY: Was the mother screened with a standardized instrument (EPDS, PHQ- 2, or PHQ-9) for possible postpartum depression by 3 months postpartum? Additional guidance The best practice is for the home visitors to perform this screen themselves. This tool should only be used by home visitors who have been oriented or trained on it. If a home visitor is not familiar with the tool or how to use it, consult with your supervisor This must be done with fidelity to the model (i.e., for NFP, a nurse completes the screening. However, the question does not specify if it s the home visitor or other health care professional doing the screening. 11 BIOLOGICAL MOTHERS ONLY: Was the mother referred to relevant community resources for screening positive for postpartum depression? (Use EPDS or PHQ-9) 12 Has your child ever had breast milk? 13 Does your child continue to get breast milk? 14 How many weeks old was your child when he or she stopped getting breast milk? 15 In the past 6 months, have you (client) obtained care at the emergency room/urgent care center for ANY reason? 16 In the past 6 months, have you (client) taken your child to the emergency room/urgent care center for an injury? The PHQ-2 is a pre-screen and if it is positive a PHQ-9 should be used. Use the tool s guidance and clinical judgment to decide whether or not the caregiver needs a referral. Refer to appendix: Maternal Depression Screening Algorithms on page 53 Examples of referrals include: Provide information about services Assist caregiver in accessing services Directly contact services with caregiver s permission Enter "1" if less than one week. Only enter integers and round up to the nearest week. It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you obtained care Specifically for injury It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you taken your child 15

6 Months Infant Question in the forms 17 In the past 6 months, have you (client) taken your child to the emergency room/urgent care center for ANY reason, including injury? 18 Does this client have a home safety checklist (or equivalent) completed? 19 Is there currently an active file at the lead Child Protection Agency (CPA) of suspected maltreatment for this child? 20 Was the suspected case of maltreatment substantiated by the lead CPA? 21 Was the child of the substantiated case of maltreatment a first-time victim, as reported by lead CPA? 22 What is the child's current weight? 23 What is the child's current length? (head-to-toe) 24 Does your agency (home visiting) have an NCAST trained staff person? 25 NCAST Teaching Subscale Scores by 3 months postpartum (initial assessment): 26 Has the home visitor discussed the child's ASQ-3 scores at 4 months of age with the primary caregiver? 27 Please indicate whether the child's ASQ-3 scores at 4 months of age were below the established referral score cutoff in the following areas? Note: Checked box = scored below the cutoff (i.e., did not meet developmental milestone) Additional guidance For any reason It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you obtained care The Home Safety Checklist (Minnesota Department of Health) is available online in English or Spanish at http://www.health.state.mn.us/divs/cfh/ program/fhv/homevisitor.cfm#tools This will likely require local public health to contact other local agencies to access this information. Not necessarily the specific home visitor assigned to the family. The NCAST can be performed by any person trained to use the NCAST. MDH provides training to use the NCAST. Only fill this out if someone trained to use the NCAST administers the assessment for the caregiver. Otherwise leave it blank. 16

6 Months Infant Question in the forms 28 (If home visitor checked any box for question 27) Was the child referred to relevant community resources for scoring below any referral score cutoff for Communication, Gross Motor, Fine Motor, Problem Solving, or Personal-Social areas on the ASQ- 3? Additional guidance Examples of referrals include: Provide information about services Assist caregiver in accessing services Directly contact services with caregiver s permission Ongoing services provided by the agency 29 Was an appointment made for further screening/assessment of the child referred to relevant community resources? 30 BIOLOGICAL MOTHERS ONLY: Was the client screened for the presence of domestic violence using the NFP Relationship Assessment or HFA Humiliation Afraid Rape Kick Child Survey (HARK-C) by 3 months postpartum? 31 Did the screening tool reveal evidence of domestic violence? 32 Was a referral made to relevant domestic violence services and noted in the client's chart? 33 Was an intimate partner violence safety plan discussed, completed, or reviewed? Services might include: health providers, Help Me Grow, private therapy services, Follow Along Program, Early Childhood Special Education (ECSE) We want to know if an appointment was made, either by the home visitor or by the caregiver. HARK-C: A cutoff score of 1 will be used as criteria for a positive screen. Source: Sohal, et. al. BMC Family Practice 2007 8:49. Examples of referrals include: Confidentially provide information about services Assist caregiver in accessing services Follow the guidance of your own agency, or access intimate partner violence resources in your county/region. 34 Are you (client) currently working? No, Not employed indicates that the person is not working for pay (this category may include, for example, students, homemakers and those actively seeking work but currently not employed). Someone who receives disability and is not currently working is No, not employed. Disability income is counted in household income question. 17

6 Months Infant Question in the forms 35 What is your (client's) household size? (Note: Count 1 for yourself) Additional guidance A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. A pregnant woman should be counted as two, taking into consideration the unborn fetus(es). 36 Which category best describes your (client's) total annual household income and benefits? Household size: total number of individuals sharing income and consumption of goods and/or services. A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. Household size: total number of individuals sharing income and consumption of goods and/or services. "Income and benefits" should include annual earnings from work rent from tenants/borders cash assistance from friends/relatives child support payments TANF Social Security (SSI/SSDI/OAI) Unemployment Insurance) Consider calculating household income in a similar way you might be determining eligibility for other services like MCH or TANF. Annual income data can be estimated from monthly data (monthly income x 12). 18

6 Months Infant Question in the forms 37 In what educational program are you (client) currently enrolled, if any? 38 What is the highest level of education you (client) have attained? 39 In the past 6 months, have you (client) completed any educational programs or classes, such as grade advancement, certificate, ESOL, etc.? Additional guidance ESOL = English for Speakers of Other Languages, also sometimes referred to as English as a Second Language (ESL) or English as a New Language (ENL) It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you completed 40 Do you (client) have health insurance? 02 No, uninsured Includes clients who have applied for insurance (pending) 41 What is your major medical care resource for health insurance? (select one or more) Home visitors who encounter caregivers who do not have health insurance coverage are encouraged to use MNsure.org for coverage options available in Minnesota state. 02 Public insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning Program 42 Does your child have health insurance? 02 No, uninsured Includes clients who have applied for insurance (pending) 43 What is your child's major medical care resource for health insurance? (select one or more) 02 Public insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning Program 19

12 Months Infant Fill out 12 months infant form when child is 10 months 0 days to 13 months 30 days Questions with more specific time requirements #25 #28 ASQ-3 (10/12 months questionnaire) follow ASQ guidance for when to complete #29 #32 ASQ:SE (12 months questionnaire) follow ASQ guidance for when to complete Question in the forms Additional guidance 1 Data entry staff (name) The person doing the data entry into your system. 2 Home visitor (name) 3 Site The health department site (county or city) where the client lives. 3b Name of subcontracting agency, if applicable Only fill this out if there is a subcontracting agency performing family home visiting. If there is a new subcontracting agency that doesn t appear on this list, contact Health.FHVdata@state.mn.us 4 Date of home visit 5 Total # home visits to-date Include the total number of visits with the caregiver, including the current visit and any previous FHV visits related to the current child. 6 Child ID 7 Primary caregiver ID 8 Legal marital status1 Select "01 Married" if the client is legally married in the United States. 9 BIOLOGICAL MOTHERS ONLY: Are you (client) taking a vitamin containing folic acid? 10 BIOLOGICAL MOTHERS ONLY: Since you had your child, have you (client) been pregnant again? 11 Has your child ever had breast milk? 12 Does your child continue to get breast milk? 13 How many weeks old was your child when he or she stopped getting breast milk? 14 Has your child had 50% of their well-child checkups? Enter "1" if less than one week. Only enter integers and round up to the nearest week. Determine number of well-child visits by use of recognized schedule, such as: Follow-along Program, AAP Recommendations for Preventive Pediatric Health Care, or the Minnesota Child and Teen Checkups (C&TC) Early and Periodic Screening, Diagnosis & Treatment Schedule of Age-Related Screening Standards. Do NOT count a well-child check-up that has been scheduled but not yet completed. 20

12 Months Infant Question in the forms 15 In the past 6 months, have you (client) obtained care at the emergency room/urgent care center for ANY reason? 16 In the past 6 months, have you (client) taken your child to the emergency room/urgent care center for an injury? 17 In the past 6 months, have you (client) taken your child to the emergency room/urgent care center for ANY reason, including injury? 18 Is there currently an active file at the lead Child Protection Agency (CPA) of suspected maltreatment for this child? 19 Was the suspected case of maltreatment substantiated by the lead CPA? 20 Was the child of the substantiated case of maltreatment a first-time victim, as reported by lead CPA? 21 What is the child's current weight? 22 What is the child's current length? (head-to-toe) 23 Does your agency (home visiting) have an NCAST trained staff person? 24 NCAST Teaching Subscale Scores at 12 months of child age 25 Has the home visitor discussed the child's ASQ-3 scores at 10/12 months of age with the primary caregiver? 26 Please indicate whether the child's ASQ-3 scores at 10/12 months of age were below the established referral score cutoff in the following areas? Note: Checked box = scored below the cutoff (i.e., did not meet developmental milestone) Additional guidance It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you obtained care Specifically for injury It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you taken your child For any reason It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you taken your child This will likely require local public health to contact other local agencies to access this information. Not necessarily the specific home visitor assigned to the family. The NCAST can be performed by any person trained to use the NCAST. MDH provides training to use the NCAST. This question is only for ASQ-3 scores at 10/12 months of age, NOT at any other age. For example, do not use this question in reference to an 8 month screen. This question is only for ASQ-3 scores at 10/12 months of age, NOT at any other age. For example, do not use this question in reference to an 8 month screen. 21

12 Months Infant Question in the forms 27 If home visitor checked any box for question 26: Was the child referred to relevant community resources for scoring below any referral score cutoff for Communication, Gross Motor, Fine Motor, Problem Solving, or Personal-Social areas on the ASQ- 3? 28 Was an appointment made for further screening/assessment of the child referred to relevant community resources? 29 Has the home visitor discussed the child's ASQ:SE scores at 12 months of age with the primary caregiver? 30 Please indicate whether the child's ASQ:SE score at 12 months of age was above the established referral score cutoff. Note: Checked box = scored above the cutoff (i.e., did not meet socio-emotional milestones) 31 (If home visitor checked the box for question 30) Was the child referred to relevant community resources for scoring above the referral score cutoff on the ASQ:SE? 32 Was an appointment made for further screening/assessment of the child referred to relevant community resources? 33 BIOLOGICAL MOTHERS ONLY: Was the client screened for the presence of domestic violence using the NFP Relationship Assessment or HFA Humiliation Afraid Rape Kick Child Survey (HARK-C)? 34 Did the screening tool reveal evidence of domestic violence? Additional guidance Examples of referrals include: Provide information about services Assist caregiver in accessing services Directly contact services with caregiver s permission Ongoing services provided by the agency Services might include: health providers, Help Me Grow, private therapy services, Follow Along Program, Early Childhood Special Education (ECSE) We want to know if an appointment was made, either by the home visitor or by the caregiver. Examples of referrals include: Provide information about services Assist caregiver in accessing services Directly contact services with caregiver s permission Ongoing services provided by the agency Services might include: health providers, Help Me Grow, private therapy services, Follow Along Program, Early Childhood Special Education (ECSE), infant mental health providers We want to know if an appointment was made, either by the home visitor or by the caregiver. This question should read: In the past 6 months. This change will be made in next year s forms. HARK-C: A cutoff score of 1 will be used as criteria for a positive screen. Source: Sohal, et. al. BMC Family Practice 2007 8:49. 22

12 Months Infant Question in the forms 35 Was a referral made to relevant domestic violence services and noted in the client's chart? 36 Was an intimate partner violence safety plan discussed, completed, or reviewed? Additional guidance Examples of referrals include: Confidentially provide information about services Assist caregiver in accessing services Follow the guidance of your own agency, or access intimate partner violence resources in your county/region. 37 Are you (client) currently working? No, Not employed indicates that the person is not working for pay (this category may include, for example, students, homemakers and those actively seeking work but currently not employed). 38 What is your (client's) household size? (Note: Count 1 for yourself) Someone who receives disability and is not currently working is No, not employed. Disability income is counted in household income question. A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. A pregnant woman should be counted as two, taking into consideration the unborn fetus(es). Household size: total number of individuals sharing income and consumption of goods and/or services. 23

12 Months Infant Question in the forms 39 Which category best describes your (client's) total annual household income and benefits? Additional guidance A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. Household size: total number of individuals sharing income and consumption of goods and/or services. "Income and benefits" should include annual earnings from work rent from tenants/borders cash assistance from friends/relatives child support payments TANF Social Security (SSI/SSDI/OAI) Unemployment Insurance) Consider calculating household income in a similar way you might be determining eligibility for other services like MCH or TANF. 40 In what educational program are you (client) currently enrolled, if any? 41 What is the highest level of education you (client) have attained? 42 In the past 6 months, have you (client) completed any educational programs or classes, such as grade advancement, certificate, ESOL, etc.? Annual income data can be estimated from monthly data (monthly income x 12). ESOL = English for Speakers of Other Languages, also sometimes referred to as English as a Second Language (ESL) or English as a New Language (ENL) It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you completed 24

12 Months Infant Question in the forms Additional guidance 43 Do you (client) have health insurance? 02 No, uninsured Includes clients who have applied for insurance (pending) 44 What is your major medical care resource for health insurance? (select one or more) Home visitors who encounter caregivers who do not have health insurance coverage are encouraged to use MNsure.org for coverage options available in Minnesota state. 02 Public insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning Program 45 Does your child have health insurance? 02 No, uninsured Includes clients who have applied for insurance (pending) 02 Public insurance includes any Minnesota 46 What is your child's major medical care resource Health Care Programs (MHCP): Medical for health insurance? (select one or more) Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning Program 25

18 Months Toddler Fill out 18 months infant form when child is 16 months 0 days to 19 months 30 days Questions with more specific time requirements #20 #23 ASQ-3 (18 months questionnaire): follow ASQ guidance for when to complete #24 #27 ASQ:SE (18 months questionnaire): follow ASQ guidance for when to complete Question in the forms Additional guidance 1 Data entry staff (name) The person doing the data entry into your system. 2 Home visitor (name) 3 Site The health department site (county or city) where the client lives. 3b Name of subcontracting agency, if applicable Only fill this out if there is a subcontracting agency performing family home visiting. If there is a new subcontracting agency that doesn t appear on this list, contact Health.FHVdata@state.mn.us 4 Date of home visit 5 Total # home visits to-date Include the total number of visits with the caregiver, including the current visit and any previous FHV visits related to the current child. 6 Child ID 7 Primary caregiver ID 8 BIOLOGICAL MOTHERS ONLY: Are you (client) taking a vitamin containing folic acid? 9 BIOLOGICAL MOTHERS ONLY: Since you had your child, have you (client) been pregnant again? 10 Has your child ever had breast milk? 11 Does your child continue to get breast milk? 12 How many weeks old was your child when he or Enter "1" if less than one week. Only enter she stopped getting breast milk? 13 In the past 6 months, have you (client) obtained care at the emergency room/urgent care center for ANY reason? 14 In the past 6 months, have you (client) taken your child to the emergency room/urgent care center for an injury? integers and round up to the nearest week. It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you obtained care Specifically for injury It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you taken your child 26

18 Months Toddler Question in the forms 15 In the past 6 months, have you (client) taken your child to the emergency room/urgent care center for ANY reason, including injury? 16 What is the child's current weight? Additional guidance For any reason It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you taken your child 17 What is the child's current length? (head-totoe) 18 Does your agency (home visiting) have an NCAST trained staff person? 19 NCAST Teaching Subscale Scores at 18 months of age: 20 Has the home visitor discussed the child's ASQ- 3 scores at 18 months of age with the primary caregiver? 21 Please indicate whether the child's ASQ-3 scores at 18 months of age were below the established referral score cutoff in the following areas? Note: Checked box = scored below the cutoff (i.e., did not meet developmental milestone) 22 (If home visitor checked any box for question 21) Was the child referred to relevant community resources for scoring below any referral score cutoff for Communication, Gross Motor, Fine Motor, Problem Solving, or Personal-Social areas on the ASQ-3? 23 Was an appointment made for further screening/assessment of the child referred to relevant community resources? 24 Has the home visitor discussed the child's ASQ:SE scores at 18 months of age with the primary caregiver? Not necessarily the specific home visitor assigned to the family. The NCAST can be performed by any person trained to use the NCAST. MDH provides training to use the NCAST. Use 18 months questionnaire Use 18 months questionnaire Use 18 months questionnaire Examples of referrals include: Provide information about services Assist caregiver in accessing services Directly contact services with caregiver s permission Ongoing services provided by the agency Services might include: health providers, Help Me Grow, private therapy services, Follow Along Program, Early Childhood Special Education (ECSE) We want to know if an appointment was made, either by the home visitor or by the caregiver. Use 18 months questionnaire 27

18 Months Toddler Question in the forms 25 Please indicate whether the child's ASQ:SE score at 18 months of age was above the established referral score cutoff. Note: Checked box = scored above the cutoff (i.e., did not meet socio-emotional milestones) 26 (If home visitor checked the box for question 29) Was the child referred to relevant community resources for scoring above the referral score cutoff on the ASQ:SE? 27 Was an appointment made for further screening/assessment of the child referred to relevant community resources? 28 BIOLOGICAL MOTHERS ONLY: Was the client screened for the presence of domestic violence using the NFP Relationship Assessment or HFA Humiliation Afraid Rape Kick Child Survey (HARK- C)? 29 Did the screening tool reveal evidence of domestic violence? 30 Was a referral made to relevant domestic violence services and noted in the client's chart? 31 Was an intimate partner violence safety plan discussed, completed, or reviewed? Additional guidance Use 18 months questionnaire Examples of referrals include: Provide information about services Assist caregiver in accessing services Directly contact services with caregiver s permission Ongoing services provided by the agency Services might include: health providers, Help Me Grow, private therapy services, Follow Along Program, Early Childhood Special Education (ECSE), infant mental health providers We want to know if an appointment was made, either by the home visitor or by the caregiver. HARK-C: A cutoff score of 1 will be used as criteria for a positive screen. Source: Sohal, et. al. BMC Family Practice 2007 8:49. Examples of referrals include: Confidentially provide information about services Assist caregiver in accessing services Follow the guidance of your own agency, or access intimate partner violence resources in your county/region. 28

18 Months Toddler Question in the forms 32 Which category best describes your (client's) total annual household income and benefits? Additional guidance A "household" is defined as a group of related or non-related individuals who are living together as one economic unit sharing income and consumption of goods and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. Household size: total number of individuals sharing income and consumption of goods and/or services. 33 In the past 6 months, have you (client) completed any educational programs or classes, such as grade advancement, certificate, ESOL, etc.? "Income and benefits" should include annual earnings from work rent from tenants/borders cash assistance from friends/relatives child support payments TANF Social Security (SSI/SSDI/OAI) Unemployment Insurance) Consider calculating household income in a similar way you might be determining eligibility for other services like MCH or TANF. Annual income data can be estimated from monthly data (monthly income x 12). ESOL = English for Speakers of Other Languages, also sometimes referred to as English as a Second Language (ESL) or English as a New Language (ENL) It might help if the home visitor makes this question more specific to the current time period. For example, if the visit happens in March, the home visitor could ask Since September, have you completed 34 Do you (client) have health insurance? 02 No, uninsured Includes clients who have applied for insurance (pending) Home visitors who encounter caregivers who do not have health insurance coverage are encouraged to use MNsure.org for coverage options available in Minnesota state. 29