MIECHV Forms Guidance

MIECHV Forms Guidance UPDATED JULY 2018

MIECHV Forms Guidance Updated July 2018 Minnesota Department of Health Family Home Visiting Section Evaluation Unit PO Box 64882, St. Paul, MN 55164-0882 651-201-4090 Health.FHVData@state.mn.us www.health.state.mn.us/fhv/ Upon request, this material will be made available in an alternative format such as large print, Braille or audio recording. Printed on recycled paper. 1

Contents MIECHV FORMS GUIDANCE Overview... 3 What Forms to Complete... 3 Which s to Complete... 5 MIECHV Forms Application... 6 s?... 6 Caregiver Intake... 7 Child Intake... 16 1st Postpartum Visit... 19 3 Months Infant... 22 6 Months Infant... 25 9 Months Infant... 29 12 Months Infant... 32 18 Months Toddler... 36 24 Months Toddler... 41 30 Months Toddler and... 46 36 Months Preschooler... 46 42-66 Months Preschooler... 50 Primary Caregiver Closure... 53 Behavioral Concerns and Child Injury s... 54 Appendices... 56 Appendix A. Terms and Acronyms... 57 Appendix B. Caregiver and Child Intake s Required for Continuing Families... 58 Appendix C. List of Validated Screening and Assessment Tools Used for MIECHV Data Collection... 60 Appendix D. Screening and Assessment Target Timeframes for MIECHV Performance Measures... 61 2

Overview MIECHV FORMS GUIDANCE This document provides guidance on how to complete questions in the MIECHV Evaluation Forms Packet (http://www.health.state.mn.us/divs/cfh/program/fhv/content/document/pdf/miechvevalfor ms.pdf). These data collection forms are used by Family Home Visiting (FHV) agencies receiving Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grant funding or state-funded Evidence-Based Home Visiting (EBHV) grants from the Minnesota Department of Health (MDH). MIECHV and EBHV grantees may elect to use the MIECHV Evaluation Forms Packet for all of their FHV clients, including clients not served by the MIECHV or EBHV grants. Grantees who choose to collect and report the data in the MIECHV Evaluation Forms Packet on non-miechv, non-ebhv clients do not need to submit data for those clients through the Family Home Visiting Reporting and Evaluation System (FHVRES). If your site wants to transition from reporting to FHVRES to reporting using the MIECHV Evaluation Forms Packet, please contact the FHV Evaluation Unit at Health.FHVData@state.mn.us to discuss a transition plan. For more information on required FHV grant reporting, including how to submit data collected using the MIECHV Evaluation Forms Packet to MDH, please refer to the current FHV Reporting Requirements document posted on the FHV Evaluation and Continuous Quality Improvement webpage. What Forms to Complete The Caregiver Intake Form is required for all FHV sets 1 submitted to MDH, regardless of type of program or model (EBHV model, Other Ongoing, or Short-Term/Limited). Complete this form as soon as possible after the first home visit with the caregiver. The Child Intake Form is required for each target child in a family. Complete a separate Child Intake form for each target child in a family. For children born to clients enrolled prenatally, complete the Child Intake form at the time of the first postpartum home visit. For children in families enrolling postpartum, complete the Child Intake form as soon as possible after the first home visit with the family. The Primary Caregiver Closure Form is required when: The caregiver and child complete the program; The caregiver and child are no longer participating in the FHV program or have been lost to follow-up and the case is being closed by the program; The caregiver-child dyad changes FHV models or programs; 1 An FHV set is defined as the record of FHV data for a client or caregiver-child dyad continuously enrolled in a particular FHV program or model from intake through closure. Dyad is defined as a pair consisting of an FHV target child and that child s primary caregiver. A caregiver may be associated with more than one dyad (for example, the parent of twins would be associated with two dyads, one for each child). Please see the current FHV Reporting Requirements document for situations when a new FHV set should be created. 3

The caregiver-child dyad moves out of the FHV program s service area (family may now be served by a different LPH site); The child s caregiver changes (e.g. parent loses custody and home visits will now be with a different caregiver). For families enrolled in an EBHV model such as NFP, HFA, or Family Spirit, or in Other Ongoing (long-term) home visiting programs, additional forms are required. These forms may also be submitted for families in short-term/limited home visiting programs, if the family reaches the form time point. Complete the 1 st Postpartum Visit form at the time of the first postpartum home visit for clients who enrolled prenatally. Do not use the 1 st Postpartum Visit form for clients who enroll after the birth of their child. Complete child age interval forms within one month (before or after) of the date that the child reaches the age specified by the form. For example, if the child reaches 3 months of age on March 1 st, the 3 Months Infant form should be completed between February 1 st and March 30 th. List of child age interval forms 3 Months Infant 6 Months Infant 9 Months Infant 12 Months Infant 18 Months Toddler 24 Months Toddler 30 Months Toddler 36 Months Preschooler 42 Months Preschooler 54 Months Preschooler 60 Months Preschooler 66 Months Preschooler Resubmission of forms Forms can be changed and re-submitted after their initial submission to MDH. If information on the form needs to be corrected, re-submit the form with the correct information. If information was missing or unavailable at the time of submission, and becomes available later, re-submit the form with the additional information: Example: when completing the section on referrals and services for developmental delays on the 9 month, 18 month, and 24 month forms, the initial date of service may not have occurred by the time the form is completed by the home visitor. In this situation, the form can be completed initially without reporting the initial date of 4

service for Early Intervention or other community services for developmental delays, and then re-submitted at a later time when that information is available. Which s to Complete Repeating questions for screenings and referrals s for intimate partner violence screening and referral, and depression screening, referral, and receipt of services repeat on many of the forms. However, if screenings and referrals have already been reported for the client within the target timeframe, subsequent screenings do not need to be performed or reported for the purpose of calculating MIECHV performance measures. The repeat of these questions does not mean that additional screenings are expected. The MIECHV target timeframes for these screenings and referrals can be found in Appendix D, Screening and Assessment Target Timeframes for MIECHV Performance Measures. s required for each model or program EBHV Models (including EHS, Family Spirit, HFA, NFP, and PAT): MDH expects all questions in the MIECHV Evaluation Forms Packet to be answered if applicable. Other, Ongoing FHV (long-term FHV programs): MDH expects all questions in the MIECHV Evaluation Forms Packet to be answered if applicable. Short-term/Limited FHV programs: required questions for short-term/limited dyads are marked with an asterisk (*) by the question number in this document, and in the PDF version of the MIECHV Evaluation Forms Packet. Additional questions should be answered if the home visitor collects the relevant information. How to answer questions on forms Leave the question blank (missing) when data has not been collected for that question. Some questions have 88 Client does not know/not sure or 99 Client declines to answer. Choose these response options only when an attempt has been made to collect the data, and the client explicitly responds that they do not know the answer to the question, or when the client refuses to respond to the question. Do not create new response categories, even if your data system allows their creation. The MIECHV Forms Application, distributed by MDH to collect the data in the MIECHV Forms Packet, will only accept values that are on the forms. Do not reword response categories, even if your data system allows this. Data submitted to MDH must have response categories that match those in the MIECHV Evaluation Forms Packet, to avoid the need for extra recoding of responses before analysis. Use the Other category and corresponding write-in comment fields only when none of the provided response categories apply. Example: when entering data on type of health insurance, do not select Other and type in Medical Assistance. Instead, select Public Insurance. Do not use personal identifiers, such as client names, in write-in comment fields. Be aware of any specific time frames referenced when answering a question. 5

Example: When answering the question Was the caregiver screened for depression using a validated tool within the past 3 months? be sure that the screening date was within the past 3 months. Be aware that some questions require the reporting of information that may have been collected at an earlier date. Example: Answering the question What was the approximate date of the child s last well-child visit? may require information that was collected at a previous visit with the family. MIECHV Forms Application If your site does not have a data system that collects the questions in the MIECHV Evaluation Forms Packet, contact Health.FHVdata@state.mn.us to get the MDH MIECHV Forms Application. The FHV Evaluation Unit can provide training to local home visiting staff on how to use the MIECHV Forms Application, in-person or via WebEx. s? Send questions about MDH FHV data collection and submission to Health.FHVData@state.mn.us. The FHV Evaluation Unit provides technical assistance on how to interpret questions, as well as help with submitting data to MDH. For technical assistance with extracting data from your local data collection system for submission to MDH, or other questions related to using local data systems, please contact your data collection system vendor. 6

Caregiver Intake MIECHV FORMS GUIDANCE s in the forms *1 Data entry staff (name) Name of the person who enters data into the data collection system. *2 Home visitor (name) Name of the home visitor serving the family. *3 Site Site providing home visiting services to the family. A Site can be a local public health agency, tribal health agency, or non-profit organization. *4 Date of first home visit The date of the first home visit after the client has been determined to be eligible and has been enrolled in home visiting. Follow model guidance if using an evidencebased home visiting model. 5 Funding Source Select all that apply: MIECHV Formula: If the client was served with MIECHV Formula funding, please check the box "01 MIECHV Formula. MIECHV Expansion: If the client was served with MIECHV Expansion funding, please check the box "02 MIECHV Expansion." TANF: If the client is TANF-eligible, please check the box for "03 TANF." MN NFP Grant: If the client was served with MN NFP Grant funding, please check the box 04 MN NFP Grant. MN EBHV Grant: If the client was served with MN EBHV Grant funding, please check the box 06 MN EBHV Grant. If none of these grants apply, leave this question blank do not select any of the response options. 7

s in the forms *6 Home visiting model Indicate the home visiting model or program type being used to deliver FHV services to the family. Specific models (HFA, NFP, EHS, PAT, Family Spirit, and Family Connects) should only be indicated if the service provider is accredited, affiliated, or otherwise recognized by the model developer as an implementing agency. Other, ongoing: Includes FHV services that are comprehensive in scope and intended to achieve long-term outcomes, but are not provided using one of the home visiting models listed above. Other, short-term/limited: Includes FHV services for assessment purposes, achieving short-term goals, or another limited purpose. Refer to the most recent FHV Reporting Requirements document for updated definitions of FHV program types. 7 Is the family transferring to MIECHV from another family home visiting program? Transfers to MIECHV can be internal (e.g. from a non- MIECHV home visiting program to MIECHV) or a transfer from another home visiting site or jurisdiction. 8 Indicate the level of informed consent to share data with the Minnesota Dept. Health for this caregiver This field tracks the level of consent obtained from the caregiver by the family home visiting agency to share data with MDH. The value of this field will affect what data is included in the export file generated by the MIECHV Forms Application. Full Consent: All data entered will be included in the export file that is created by the MIECHV Java Forms program. Exclude Personal identifiers: Names and street addresses will be excluded from the export file. No consent: None of the clients data will be included in the export file. NOTE: Clients can change their level of informed consent at any time. If a client changes their level of consent, enter the new level in this field on the Caregiver Intake form. Future data submissions from the MIECHV Forms Application will reflect the updated level of consent. 9 First name First name of the primary caregiver. 10 Middle Initial Primary caregiver's middle initial. 11 Last name Last Name of the primary caregiver. 12 Maiden name, if applicable Maiden last name of primary caregiver, if applicable. *13 Birth date Primary caregiver's date of birth. 8

s in the forms *14 Caregiver ID Unique identifier assigned to the primary caregiver. This ID number is used to match data collected on the MIECHV Evaluation Forms with other FHV data submissions, including visit-level data. 15 Caregiver ID #2 Additional unique identifier assigned to the primary caregiver (optional). Sites may choose to populate this field to facilitate linkage to other data systems. 16 Family ID Unique identifier assigned to the family or household (optional). 17 Home address (number and Primary caregiver's home address. street or rural route) 18 City Primary caregiver's city of residence. 19 County Primary caregiver's county of residence. NOTE: this may differ from the county where the service provider ( Site ) is located. 20 State Primary caregiver's state of residence. 21 Zip Code Primary caregiver's zip code of residence. 22 Is the caregiver homeless? Indicate whether the primary caregiver is homeless at the time the form is completed. Homeless is defined as lacking a fixed, regular, and adequate nighttime residence. This includes clients that are currently living with someone else temporarily due to economic hardship or lack of alternatives. 9

s in the forms 23 If home visitor checked box "01 Not Homeless": Which of the following best describes the caregiver's living arrangements? Indicate the primary caregiver s living arrangement at the time the form is completed. Owns or shares own home, apartment, etc.: individuals who own their housing, or share housing with the homeowner on a long-term basis. Rents or shares rented home or apartment: individuals who rent their housing, or share housing with the renter on a long-term basis. Lives in public housing: individuals who live in an affordable public housing unit under the US Dept of Housing and Urban Development (HUD) public housing program. o NOTE: this does not include Section 8 housing assistance/housing choice vouchers. Individuals using housing choice vouchers to rent housing should be reported under Rents or shares rented home or apartment. Lives with parent or family member: individuals who live with a parent or family member, who are not reported under Owns or shares own home or rents or shares rented home. This includes adolescent primary caregivers who are living with their parent(s) or other family members, where the parent(s) or family members are the homeowner or renter. Not Homeless Some other arrangement: individuals who are not homeless as defined above, and who do not fall into the other categories. 10

s in the forms 24 If home visitor checked box "02 Homeless": Which of the following best describes the caregiver's living arrangements? Indicate the primary caregiver s living arrangement at the time the form is completed. Homeless and sharing housing: individuals who are sharing the housing of other persons due to the loss of housing, economic hardship, or a similar reason. Homeless and living in an emergency or transitional shelter: individuals who are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement. Homeless Some other arrangement: individuals who are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; individuals who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; individuals who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings. 25 Caregiver type at enrollment (relationship to index child) Select the category that describes the primary caregiver s status at the time of enrollment in home visiting in the current FHV model, with the current service provider. Pregnant woman: primary caregivers who are pregnant at the time of enrollment in home visiting. Postpartum mother (biological): primary caregivers who are the biological mother of the index child served by home visiting. Father: primary caregivers who are the father of the index child served in home visiting includes biological and non-biological fathers. Other caregiver: primary caregivers who do not fall into one of the other categories. 25.1 Other caregiver: If Other caregiver is selected for the previous question, specify (examples: foster parent, aunt/uncle, grandparent). 26 Gender Primary caregiver s gender. Clients should be allowed to choose the response that fits best (self-report). Do not answer this question based on the home visitor s observation or best guess. 11

s in the forms 27 Hispanic or Latino/a ethnicity Primary caregiver s Hispanic or Latino/a ethnicity. Clients should be allowed to choose the response that fits best (self-report). Do not answer this question based on the home visitor s observation or best guess. People who identify their ethnicity as Hispanic or Latino/a may be of any race. 28 Race (choose all that apply): Primary caregiver s race. Clients should be allowed to choose the response(s) that fits best (self-report). Do not answer this question based on the home visitor s observation or best guess. If a client considers themselves to be more than one race, select all that apply. 28.1 Other (specify): If Other is selected for the previous question, please specify based on the primary caregiver s self-description. 29 Primary language The language that is spoken in the home most of the time. 29.1 Other (specify): If the language that is spoken in the home most of the time is not listed above, enter the specific language here. 30 Legal marital status Primary caregiver s legal marital status at the time the form is completed. NOTE: Report legal marital status only. Caregivers who are culturally married, but whose marriage is not recognized by the state, should not be reported as married. 31 Does the caregiver currently live with their spouse or partner? Based on primary caregiver s self-report. 32 PRENATAL CAREGIVERS ONLY: What is the Estimated Date of Delivery (EDD)? 33 Does the caregiver currently use tobacco, such as cigarettes, cigars, chewing tobacco, or electronic cigarettes (excluding religious or ceremonial use)? 34 Was the caregiver referred to tobacco/smoking cessation counseling or services? For primary caregivers who are pregnant, report the estimated date of delivery. This may be estimated by adding 280 days to the first day of the last menstrual period (LMP), or reported based on the caregiver s recall from discussions with their health care provider. Select No for this question if the primary caregiver s only current use of tobacco is for religious or ceremonial purposes. If the caregiver is already participating in a smoking cessation program, select 03 Client already enrolled in a cessation program. 34.1 If Yes, Date: Date of tobacco/smoking cessation referral, if made 12

s in the forms 35 Does the caregiver have a history of substance abuse or substance abuse treatment? 36 Was the caregiver found to need substance abuse services based on substance abuse screening or clinical judgment? 37 As a child, was the caregiver emotionally or physically abused by a parent or guardian, a family member, or other adult? 38 Has the caregiver ever been involved with child welfare services, either as a child or as an adult? 39 Is the caregiver currently working? 40 Which category best describes the caregiver's household monthly income, including benefits? Based on primary caregiver s self-report. Answer this question based on the results of a substance abuse screening tool, or based on the home visitor s clinical judgement that the caregiver should be referred to substance abuse services. Based on primary caregiver s self-report. Based on primary caregiver s self-report. Employed full-time is defined as working 30 or more hours per week. This may be at one job, or a combination of two or more jobs. If employment hours vary from week to week, ask the primary caregiver to select a response based on the average number of hours worked per week. If employment is seasonal, report level of employment at the time of assessment. If the primary caregiver is on parental leave from a job, and will return to that job at the end of the leave, respond to this question according to the number of hours worked prior to the parental leave. Include the total of all income received by all members of the primary caregiver s household, monthly, before taxes (gross income). Include income from: work rent from tenants/boarders cash assistance from friends/relatives child support payments MFIP and other cash assistance programs Social Security (SSI/SSDI/OAI) Unemployment benefits If it is easier for the caregiver to provide annual income, divide the annual amount by 12 to estimate monthly income. See household size question below for definition of a household. 13

s in the forms 41 How many people are in the caregiver's household (including the caregiver)? 42 Has anyone in the caregiver's household ever served in the U.S. Armed Forces, either active duty or reserves? 43 Is the caregiver currently enrolled in high school, college, or another educational program? Household is defined as a group of related or nonrelated individuals who are living together as one economic unit, sharing income and consumption of goods and/or services, who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver. Tenants/boarders shall not be counted as members of the household. Pregnant women should be counted as two (2) people when determining household size. Based on primary caregiver s self-report. For this question, this includes a military member's dependent acquired through marriage, adoption, or other action during the course of a member's current tour of assigned duty. Based on primary caregiver s self-report. 43.1 Other (specify): If Other is selected for the previous question, specify other type of educational program enrollment. 44 What is the highest level of education the caregiver has completed? Based on primary caregiver s self-report. 44.1 Other (specify): If Other is selected for the previous question, specify other type of educational program completed. 45 Does the caregiver feel that s/he has or had low achievement in school? 46 Does the caregiver currently have health insurance? Based on primary caregiver s self-report. One suggested way to collect this information is by asking the client whether they feel they struggled in school. Note that insurance status is different from access to health care services. A primary caregiver may receive care from a safety net health care provider such as an FQHC, or from Indian Health Service, but still not be covered by health insurance. Client applied for coverage, application is pending: Select this response if the caregiver has completed and submitted an application for health insurance coverage (such as MNSure, MN Health Care Programs, or private insurance), and is currently waiting for a decision from the insurer. Home visitors who encounter families who do not have health insurance coverage are encouraged to refer to MNSure (https://www.mnsure.org/). 14

s in the forms 47 What type of health plan or health insurance does the caregiver currently have? (select one or more) Private Insurance includes group insurance coverage such as through a job, and individual plans purchased through MNSure. Public Insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), and MinnesotaCare. Military Health Care includes TRICARE, CHAMPVA, or other military health insurance. 47.1 Other (specify): If Other is selected for the previous question, specify other type of health insurance coverage for the primary caregiver. 48 Are there any children in the caregiver s household with disabilities or developmental delays? Based on primary caregiver s self-report. This includes children who are not the target child for the home visiting program. 15

Child Intake MIECHV FORMS GUIDANCE s in the forms *1 Data entry staff (name) See Caregiver Intake *2 Home visitor (name) See Caregiver Intake *3 Site See Caregiver Intake *4 Form date Date on which this form was completed. This date should not be changed if additional data is added or updated at a later date. 5 First name (child) First name of the child. 6 Middle Initial (child) Child s middle initial. 7 Last name (child) Last name of the child. 8 Birth date (child) Child s date of birth. *9 Child ID Unique identifier assigned to the child. Each target child in a family should have their own identifier (for example, a family with twins will have a separate ID number for each twin). 10 Child ID#2 Additional unique identifier assigned to the Child (optional). Sites may choose to populate this field to facilitate linkage to other data systems. *11 Caregiver ID Unique identifier assigned to the child s primary caregiver. This identifier will be used to match the target child on this form with a primary caregiver. 12 Family ID See Caregiver Intake 13 Gender Child Gender see guidance on Caregiver Intake form for Caregiver Gender 14 Hispanic or Latino/a ethnicity Child Ethnicity see guidance on Caregiver Intake form for Caregiver Ethnicity 15 Race (choose all that apply): Child Race see guidance on Caregiver Intake form for Caregiver Race 15.1 Other (specify): If Other is selected for the previous question, please specify based on the primary caregiver s description. 16 What was the child's gestational age at birth? 17 What was the child's birth weight? Report gestational age in weeks and days. Report gestational age in pounds and ounces. 16

s in the forms 18 Was there more than one live birth associated with this pregnancy? Select Yes if the child is part of a set of twins, triplets, etc. 18.1 If yes, how many live births? For example, if the child is one of a set of twins, indicate 2 19 Is the child currently being breastfed or receiving breast milk? 20 What was the approximate date of the child's most recent wellchild visit? 21 Which well-child visit occurred on this date? 22 Where does the caregiver usually seek medical care for the child? Select 03 Client is not recommended to breastfeed because of a medical condition if the client has a contraindication to breastfeeding or giving the infant their pumped breastmilk. Infant diagnosed with galactosemia HIV positive status of mother Mother taking antiretroviral medications Mother has untreated, active TB Mother is infected with human T-cell lymphotropic virus type I or type II (HTLV-I or HTLV-II) Mother is using or is dependent on an illicit drug Mother is taking prescribed cancer chemotherapy agents Mother is undergoing radiation therapies See Contraindications to breastfeeding: http://www.cdc.gov/breastfeeding/disease/ for more information. If the caregiver cannot recall the exact date, please provide the approximate date or best guess. Indicate which well child visit is represented by the date reported above. Refer to the AAP well-child visit periodicity schedule: AAP Recommendations for Preventive Pediatric Health Care Child s usual source of medical care: the particular medical professional, doctor's office, clinic, health center, or other place where a person would usually go if sick or in need of advice about their child's health. Federally Qualified Health Centers (FQHCs): A list of Minnesota FQHCs can be found on the MDH website: Minnesota Federally Qualified Health Centers 2015 22.1 Other: If Other is selected for the previous question, specify other usual source of medical care for child. 23 Does the caregiver place the child to sleep on their back? Based on caregiver self-report of whether they always, sometimes, or never engage in this sleep practice. 17

s in the forms 24 Does the caregiver place the child to sleep without bed sharing? 25 Does the caregiver place the child to sleep without soft bedding? 26 Do family members read to, tell stories to, or sing to the child every day during a typical week? Based on caregiver self-report of whether they always, sometimes, or never engage in this sleep practice. Based on caregiver self-report of whether they always, sometimes, or never engage in this sleep practice. To accurately assess this measure, caregivers should be asked if their children were (1) read to, (2) told stories to, and/or (3) sang songs to every day during a typical week. Note that the measure asks parents to reflect on a typical week and then to report if at least one of the activities occurred each day during the week. Any combination of these activities over the week meets the criteria and indicates caregiver support of early language and literacy activities. 27 Does the child currently have health insurance? 28 What type of health plan or health insurance coverage does the child currently have? (select one or more) The family member(s) reading, singing, or telling stories to the child can be any family member, not just the primary caregiver. Note that insurance status is different from access to health care services. A child may receive care from a safety net health care provider such as an FQHC, or from Indian Health Service, but still not be covered by health insurance. Client applied for coverage, application is pending: Select this response an application for health insurance coverage (such as MNSure, MN Health Care Programs, or private insurance) has been completed and submitted for the child, and the family is currently waiting for a decision from the insurer. Home visitors who encounter families who do not have health insurance coverage are encouraged to refer to MNSure (https://www.mnsure.org/). Private Insurance includes group insurance coverage such as through a job, and individual plans purchased through MNSure. Public Insurance includes any Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), and MinnesotaCare. Military Health Care includes TRICARE, CHAMPVA, or other military health insurance. 28.1 Other (specify): If Other is selected for the previous question, specify other type of health insurance coverage for the child. 18

1st Postpartum Visit s in the forms *1 Data entry staff (name) See Caregiver Intake *2 Home visitor (name) See Caregiver Intake *3 Site See Caregiver Intake *4 Date of first postpartum home visit *5 Child ID *6 Caregiver ID See Caregiver Intake 7 Family ID See Caregiver Intake 8 Home address (number and street or rural route) Date of 1st postpartum home visit. This date should not be changed if additional data is added or updated at a later date. See Caregiver Intake 9 City See Caregiver Intake 10 County See Caregiver Intake 11 State See Caregiver Intake 12 Zip Code See Caregiver Intake 13 Is the caregiver homeless? Indicate whether the client is homeless or not at the time of this visit. See Caregiver Intake for additional guidance. 14 If home visitor checked box "01 Not Homeless": Which of the following best describes the caregiver's living arrangements? See Caregiver Intake 15 If home visitor checked box "02 Homeless": Which of the following best describes the caregiver's living arrangements? See Caregiver Intake 16 Legal marital status 17 Does the caregiver currently live with their spouse or partner? 19

s in the forms 18 Since enrollment in home visiting, was the caregiver screened for intimate partner violence using a validated tool? MIECHV sites must use a screening instrument approved by MDH for their MIECHV clients. See Appendix C, List of Validated Screening and Assessment Tools Used for MIECHV Data Collection. 18.1 IPV Screen Date: Date of IPV screening, if performed. Note that clients may disclose that they are experiencing IPV without having been screened. 19 What was the result of the intimate partner violence screening? 20 Was the caregiver provided with referral information to IPV resources? Use your model's or other evidence-based criteria for interpreting the results of the IPV screening. Clients may be referred even if the screening for IPV was not positive, or if in the clinical judgment of the home visitor a referral is warranted. 20.1 IPV referral date: Date of IPV resource referral, if made. 21 Is the caregiver currently working? 22 Which category best describes the caregiver's household monthly income, including benefits? 23 How many people are in the caregiver's household (including the caregiver)? 24 Has anyone in the caregiver's household ever served in the U.S. Armed Forces, either active duty or reserves? 25 Is the caregiver currently enrolled in high school, college, or another educational program? 25.1 Other (specify): If Other is selected for the previous question, specify other type of educational program enrollment. 26 What is the highest level of education the caregiver has completed? 26.1 Other (specify): If Other is selected for the previous question, specify other type of educational program completed. 27 Does the caregiver currently have health insurance? 20

s in the forms 28 What type of health plan or health insurance does the caregiver currently have? (select one or more) 28.1 Other (specify): If Other is selected for the previous question, specify other type of health insurance coverage for the primary caregiver. 29 Has there been any time in the past 6 months when the caregiver did not have health insurance? 30 Are there any children in the caregiver s household with disabilities or developmental delays? Ask the caregiver to recall to the best of their ability whether they had a gap in their health insurance coverage. Gaps may occur as the result of changes in employment, household composition, income, or other factors or life events. If the caregiver was retroactively enrolled in health insurance, such as Medical Assistance, such that they were covered for the past 6 months, indicate that No, there was no break in health insurance coverage. Indicate the status as of this visit. See Caregiver Intake for additional guidance. 21

3 Months Infant MIECHV FORMS GUIDANCE s in the forms *1 Data entry staff (name) See Caregiver Intake *2 Home visitor (name) See Caregiver Intake *3 Site See Caregiver Intake *4 Form date Date on which this form was completed. This date should not be changed if additional data is added or updated at a later date. 5 Is the family actively participating in home visiting as of the form date? A Yes response means that the family is enrolled in home visiting services and is actively participating with the home visitor in home visits as of the form date. A No response indicates that the family is not currently participating in home visits (due to unreachability or other factors), but has not yet been closed as of the form date. For example, HFA families on Creative Outreach. *6 Child ID *7 Caregiver ID See Caregiver Intake 8 Family ID See Caregiver Intake 9 Is the child currently being breastfed or receiving breast milk? 10 What was the approximate date of the child's most recent wellchild visit? 11 Which well-child visit occurred on this date? 22

s in the forms 12 BIOLOGICAL MOTHERS ONLY: Did caregiver have a postpartum visit with a healthcare provider after child birth? Select Yes if the caregiver if the child s biological mother, and had a postpartum care visit with their healthcare provider. Postpartum Visit: a visit between the woman and her health care provider to assess the mother s current physical health, including the status of pregnancy-related conditions such as gestational diabetes, to screen for postpartum depression, to provide counseling on infant care and family planning, and to provide screening and referrals for the management of chronic conditions. Additionally, a provider may use this opportunity to conduct a breast exam and discuss breastfeeding. While there is no restriction on the types of health care providers that are seen in a postpartum visit, the purpose of the visit has to be for one of the reasons outlined above. 12.1 Date of visit: If Yes selected for the previous question, report the date of the postpartum visit. If the caregiver cannot recall the exact date, please provide an approximate date or best guess. 13 Was the caregiver screened for depression using a validated tool before the index child turned 3 months of age? A list of validated depression screening tools for MIECHV clients is located in Appendix C, List of Validated Screening and Assessment Tools Used for MIECHV Data Collection. 13.1 Depression Screening Date If Yes selected for the previous question, report the date of the screening. 14 Did the screening results indicate possible depression? 15 Was the caregiver provided with referral information to mental health resources? 16 Has the caregiver received any services for depression since the child was born? 17 Does the caregiver place the child to sleep on their back? 18 Does the caregiver place the child to sleep without bed sharing? Use your model's or other evidence-based criteria for interpreting the results of the depression screening. Clients may be referred based on the judgment of the home visitor that a referral to mental health services for further assessment is warranted, as well as based on the results of depression or other mental health screening. This can be based on the client s self-report. This question will be used to determine whether referrals for depression-related services were completed. 23

s in the forms 19 Does the caregiver place the child to sleep without soft bedding? 20 Were the caregiver and child screened with a validated tool used to observe caregiver-child interaction by 3 months of age? MIECHV sites must use a parent-child interaction tool approved by MDH for their MIECHV clients. See Appendix C, List of Validated Screening and Assessment Tools Used for MIECHV Data Collection. 20.1 Screening date: Indicate the date of caregiver-child interaction observation. 21 Do family members read to, tell stories to, or sing to the child every day during a typical week? 22 Since child intake, was the caregiver screened for intimate partner violence using a validated tool? See 1 st Postpartum Visit Form 22.1 IPV Screen Date: See 1 st Postpartum Visit Form 23 What was the result of the intimate partner violence screening? 24 Was the caregiver provided with referral information to IPV resources? See 1 st Postpartum Visit Form See 1 st Postpartum Visit Form 24.1 IPV referral date: See 1 st Postpartum Visit Form 24

6 Months Infant MIECHV FORMS GUIDANCE s in the forms *1 Data entry staff (name) See Caregiver Intake *2 Home visitor (name) See Caregiver Intake *3 Site See Caregiver Intake *4 Form date Date on which this form was completed. This date should not be changed if additional data is added or updated at a later date. 5 Is the family actively participating in home visiting as of the form date? *6 Child ID See 3 Months Infant form for guidance. *7 Caregiver ID See Caregiver Intake 8 Family ID See Caregiver Intake 9 Home address (number and See Caregiver Intake street or rural route) 10 City See Caregiver Intake 11 County See Caregiver Intake 12 State See Caregiver Intake 13 Zip Code See Caregiver Intake 14 Is the caregiver homeless? Indicate whether the client is homeless or not at the time of this evaluation. See Caregiver Intake for additional guidance. 15 If home visitor checked box "01 Not Homeless": Which of the following best describes the caregiver's living arrangements? See Caregiver Intake 16 If home visitor checked box "02 Homeless": Which of the following best describes the caregiver's living arrangements? See Caregiver Intake 17 Legal marital status 18 Does the caregiver currently live with their spouse or partner? 25

s in the forms 19 Is the child currently being breastfed or receiving breast milk? 20 What was the approximate date of the child's most recent wellchild visit? 21 Which well-child visit occurred on this date? 22 Was the caregiver screened for depression using a validated tool in the past 3 months? See 3 months infant form for guidance. 22.1 Depression Screening Date See 3 months infant form 23 Did the screening results indicate possible depression? 24 Was the caregiver provided with referral information to mental health resources? See 3 months infant form See 3 months infant form 25 Has the caregiver received any services for depression in the past 3 months? 26 Where does the caregiver usually seek medical care for the child? See 3 months infant form 26.1 Other: If Other is selected for the previous question, specify other usual source of medical care for child. 27 Does the caregiver have a dentist that they can take their child to? 28 Does the caregiver place the child to sleep on their back? 29 Does the caregiver place the child to sleep without bed sharing? Usual source of dental care: a usual source of dental care, or dental home, means that a child s oral health care is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist. Clinical guidelines are that a dental home should be established no later than 12 months of age. Note that for this question, the child does not have to have been seen by a dentist as of the assessment date, but rather the caregiver has a dentist that the child could be taken to. 26

s in the forms 30 Does the caregiver place the child to sleep without soft bedding? 31 Do family members read to, tell stories to, or sing to the child every day during a typical week? 32 In the past 3 months, was the caregiver screened for intimate partner violence using a validated tool? See 1 st Postpartum Visit Form 32.1 IPV Screen Date: See 1 st Postpartum Visit Form 33 What was the result of the intimate partner violence screening? 34 Was the caregiver provided with referral information to IPV resources? See 1 st Postpartum Visit Form See 1 st Postpartum Visit Form 34.1 IPV referral date: See 1 st Postpartum Visit Form 35 Is the caregiver currently working? 36 Which category best describes the caregiver's household monthly income, including benefits? 37 How many people are in the caregiver's household (including the caregiver)? 38 Has anyone in the caregiver's household ever served in the U.S. Armed Forces, either active duty or reserves? 39 Is the caregiver currently enrolled in high school, college, or another educational program? 39.1 Other (specify): If Other is selected for the previous question, specify other type of educational program enrollment. 27

s in the forms 40 What is the highest level of education the caregiver has completed? 40.1 Other (specify): If Other is selected for the previous question, specify other type of educational program completed. 41 Does the caregiver currently have health insurance? 42 What type of health plan or health insurance does the caregiver currently have? (select one or more) 42.1 Other (specify): If Other is selected for the previous question, specify other type of health insurance coverage for the primary caregiver. 43 Has there been any time in the past 6 months when the caregiver did not have health insurance? 44 Does the child currently have health insurance? 45 What type of health plan or health insurance coverage does the child currently have? (select one or more) Indicate the client s status as of this visit. See 1 st Postpartum Visit Form for additional guidance. Indicate the child s status as of this visit. for additional guidance. Indicate the child s status as of this visit. for additional guidance. 45.1 Other (specify): If Other is selected for the previous question, specify other type of health insurance coverage for the child. 46 Are there any children in the caregiver s household with disabilities or developmental delays? Indicate the status as of this visit. See Caregiver Intake for additional guidance. 28

9 Months Infant MIECHV FORMS GUIDANCE s in the forms *1 Data entry staff (name) See Caregiver Intake *2 Home visitor (name) See Caregiver Intake *3 Site See Caregiver Intake *4 Form date Date on which this form was completed. This date should not be changed if additional data is added or updated at a later date. 5 Is the family actively participating in home visiting as of the form date? See 3 months infant form for guidance. *6 Child ID *7 Caregiver ID See Caregiver Intake 8 Family ID See Caregiver Intake 9 Is the child currently being breastfed or receiving breast milk? 10 What was the approximate date of the child's most recent wellchild visit? 11 Which well-child visit occurred on this date? 12 Was the caregiver screened for depression using a validated tool in the past 3 months? See 3 months infant form for guidance. 12.1 Depression Screening Date See 3 months infant form 13 Did the screening results indicate possible depression? 14 Was the caregiver provided with referral information to mental health resources? 15 Has the caregiver received any services for depression in the past 3 months? 16 Do family members read to, tell stories to, or sing to the child every day during a typical week? See 3 months infant form See 3 months infant form See 3 months infant form 29

s in the forms 17 Was the child screened for developmental delays using the ASQ-3 at 9 months of age? MIECHV sites must use the ASQ-3 for their MIECHV clients. See Appendix C, List of Validated Screening and Assessment Tools Used for MIECHV Data Collection, for guidance on the screening window for this time point. If the child is being served by Early Intervention (EI) or Early Childhood Special Education (ECSE), and the local EI/ECSE program is performing regular developmental screening and coordinating with public health home visiting, and therefore the home visitor is not performing developmental screening for this child, select 03 Child being served by Early Intervention for developmental delays. 17.1 Screening date: Date of developmental screening with the ASQ-3. 18 What are the results of the ASQ- 3 screening at 9 months of age? 19 Indicate which of the following developmental referrals were offered (check all that apply) 19.1 Home Visitor Support: Date of referral 19.2 Home Visitor Support: Initial date of service 19.3 Home Visitor Support: Caregiver refused referral 19.4 Early Intervention: Date of referral 19.5 Early Intervention: Initial date of service 19.6 Early Intervention: Caregiver refused referral 19.7 Early Intervention: Unable to get services Use the cut off scores for the specific ASQ-3 questionnaire that was used for the developmental screening. Indicate all types of referrals that were offered to the family. Indicate referral date, whether or not family refused referral, and initial date of service for each type of referral on subsequent items. Date that home visitor offered individualized developmental support, if applicable Date that the child first received individualized developmental support from the home visitor, if applicable Check this box if the home visitor offered individualized developmental support as a referral type, and the caregiver refused Date that home visitor offered referral to Early Intervention for assessment, if applicable Date that the child first received assessment or other services from Early Intervention, if applicable. If the exact date is not available or cannot be recalled, please estimate. Check this box if the home visitor offered referral to EI and the caregiver refused. Check this box if the home visitor referred to EI and the family was unable to receive assessment or services due to barriers such as scheduling, transportation, or other issues. 30

s in the forms 19.8 Other Community Services: Date of referral 19.9 Other Community Services: Initial date of service 19.10 Other Community Services: Caregiver refused referral 20 In the past 3 months, was the caregiver screened for intimate partner violence using a validated tool? Date that home visitor offered referral to other community services, including medical and mental health providers, drop-in centers, parent-child groups, early literacy supports, and parent training programs, if applicable Date that the child first received other community services, if applicable. If the exact date is not available or cannot be recalled, please estimate. Check this box if the home visitor offered referral to other community services and the caregiver refused. See 1 st Postpartum Visit Form 20.1 IPV Screen Date: See 1 st Postpartum Visit Form 21 What was the result of the intimate partner violence screening? 22 Was the caregiver provided with referral information to IPV resources? See 1 st Postpartum Visit Form See 1 st Postpartum Visit Form 22.1 IPV referral date: See 1 st Postpartum Visit Form 31