Form 1 MCHB Block Grant Guidance for Application/Annual Report

Maternal and Child Health Services Block Grant Report

FINAL Application_Report AttachCGuidance_10-31-11 (2)

Maternal and Child Health Services Block Grant Report

OMB: 0915-0172

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TITLE V MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO STATES PROGRAM

GUIDANCE AND FORMS

FOR THE

TITLE V APPLICATION/ANNUAL REPORT

OMB NO: 0915-0172

EXPIRES: DATE TBD

U.S. Department of Health and Human Services

Health Resources and Services Administration

Maternal and Child Health Bureau

Division of State and Community Health

Room 18-31

5600 Fishers Lane, Rockville, MD 20857

(Phone 301-443-2204 FAX 301-443-9354)

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0172. Public reporting for this collection of information is estimated to average 246 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.

TITLE V MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO STATES PROGRAM

APPLICATION/ANNUAL REPORT GUIDANCE

SIXTH EDITION

As one of the largest Federal block grant programs, Title V is the key source of support for promoting and improving the health of all the Nation’s mothers and children. When Congress passed the Social Security Act in 1935, it contained the initial key landmark legislation which established Title V. This legislation is the origin of the Federal Government’s pledge of support to States and their efforts to extend and improve health and welfare services for mothers and children throughout the Nation. To date, the Title V Federal-State partnership continues to provide a dynamic program to improve the health of all mothers and children, including children with special health care needs.

Each year, all States and jurisdictions are required to submit an Application/Annual Report for Federal funds for their Title V Maternal and Child Health (MCH) Services Block Grant to States Program to the Maternal and Child Health Bureau (MCHB) in the Health Resources and Services Administration (HRSA). All the information and instructions for the preparation and submission are contained in this Title V MCH Services Block Grant to States Program Guidance and Forms for the Title V Application/Annual Report (Guidance) document. The Guidance has undergone changes and revisions with each published edition. Over time, the previous editions of the Guidance represent the legislative changes and requirements passed by Congress. Each edition of the Guidance was developed in consultation with State Maternal and Child Health (MCH) Directors and Children with Special Health Care Needs (CSHCN) Directors. Further, each edition of the Guidance has described the experience upon which changes were made and improvements in each subsequent edition. Following this tradition, this sixth edition involved a committee of State MCH and CSHCN Directors, public health scholars, along with parent representation, working with the Division of State and Community Health (DSCH) staff to create the new Guidance. As with previous editions, this sixth edition reflects changes designed to both improve and facilitate the preparation and the submission of the Application/Annual Report by the 50 States and 9 jurisdictions.

This is the fourth edition of the Guidance issued since the Title V MCH Services Block Grant to States Program Application /Annual Report became a Web-based application. For the nine consecutive years (2003-2011) preceding this edition, States have submitted the application via a secure Web-based server as authorized by HRSA. The use of this online method for completing and submitting the Application /Annual Reports continues to be required of all 50 States and 9 jurisdictions. This latest edition of the Guidance will continue to enhance the quality of submissions and the resultant availability of data output.

Any questions and comments regarding this edition of the Guidance may be addressed to:

Cassie B. Lauver, ACSW, Director

Division of State and Community Health

Maternal and Child Health Bureau

Health Resources and Services Administration

Room 18-31, Parklawn Building

5600 Fishers Lane

Rockville, Maryland 20857

Telephone: (301) 443-2204

Fax: (301) 443-9354

[email protected]

Shape2 Shape1 Shape3 Shape5

POPULATION-BASED SERVICES:

Examples:

Newborn Screening, Lead Screening, Immunization,

Sudden Infant Death Syndrome Counseling, Oral Health,

Injury Prevention, Nutrition,

and Outreach/Public Education

INFRASTRUCTURE BUILDING SERVICES:

Examples:

Needs Assessment, Evaluation, Planning, Policy Development,

Coordination, Quality Assurance, Standards Development, Monitoring,

Training, Applied Research, Systems of Care, and Information Systems

CORE PUBLIC HEALTH SERVICES

DELIVERED BY MCH AGENCIES

MCHB/DSCH 10/20/97

Figure 1

DIRECT

HEALTH CARE

SERVICES:

(GAP FILLING)

Examples:

Basic Health Services,

and Health Services for CSHCN

ENABLING SERVICES:

Examples:

Transportation, Translation, Outreach,

Respite Care, Health Education, Family

Support Services, Purchase of Health Insurance,

Case Management, Coordination with Medicaid,

WIC, and Education

THE MCH PYRAMID

The conceptual framework for the services of the Title V MCH Services Block Grant to States Program is envisioned as a pyramid, as depicted on the previous page. The pyramid illustrates four tiers of services and levels of funding that provide comprehensive services for all mothers and children, including children with special health care needs in the Nation. This model displays the uniqueness of the Title V MCH Services Block Grant to States Program, which is the only Federal program providing services at all levels. These services are direct health care services (gap filling), enabling services, population-based services, and infrastructure building. Since 1997, the MCH Pyramid has, over time, been the graphic representation of the Title V MCH Services Block Grant to States Program.

TITLE V MATERNAL AND CHILD HEALTH SERVICES

BLOCK GRANT TO STATES PROGRAM

APPLICATION AND ANNUAL REPORT GUIDANCE

TABLE OF CONTENTS

PART ONE

BACKGROUND AND ADMINISTRATIVE INFORMATION

Page

I. HISTORY AND PURPOSE 11

A. The Maternal and Child Health Bureau 11

B. Maternal and Child Health Services Block Grant (Title V) 11

II. LEGISLATIVE REQUIREMENTS 15

A. Who Can Apply for Funds [Section 505(a)] 15

B. Use of Allotment Funds [Section 504] 15

C. Application for Block Grant Funds [Section 505] 15

D. Annual Report [Section 506] 16

E. Administration of Federal and State Programs [Section 509] 17

III. BLOCK GRANT APPLICATION/ANNUAL REPORT PREPARATION
AND SUBMISSION 17

A. Deadline for Application/Annual Report 17

B. Electronic Submission 17

C. General Information on Preparation and Submission 18

IV. APPLICATION REVIEW PROCESS 21

PART TWO

INSTRUCTIONS FOR COMPLETING THE APPLICATION/ANNUAL REPORT

GENERAL REQUIREMENTS 24

Letter of Transmittal 24
Face Sheet 24
Assurances and Certifications 24
Table of Contents 24
Public Input [Section 505(a)] 24

NEEDS ASSESSMENT ………………………………………………………………26

Needs Assessment - Background and Conceptual Framework 26
Needs Assessment Summary Update: Interim Years 29

STATE OVERVIEW 32

Overview of the State 32
Agency Capacity 32
Organizational Structure 33
Other (MCH) Capacity 34
State Agency Coordination 34
Health Systems Capacity Indicators 35

PRIORITIES, PERFORMANCE, AND PROGRAM ACTIVITIES

APPLICATION/ANNUAL REPORT 37

Background and Overview 37
State Priorities 39
National Performance Measures 39
State Performance Measures 43
Health Status Indicators 43
Other Program Activities 46
Technical Assistance Needs 46

BUDGET NARRATIVE 47

Expenditures 47
Budget 47

REPORTING FORMS - GENERAL INFORMATION AND FORMS 1 - 11 48

Application for Federal Assistance 53
MCH Budget Details for FY__ 56
State MCH Funding Profile 58
Budget Details by Types of Individuals Served (I) and
Sources of Other Federal Funds (II) 63
State Title V Program Budget and Expenditures by
Types of Service 67
Number and Percentage of Newborns and Others Screened,
Cases Confirmed, and Treated 71
Number of Individuals Served Under Title V 73
Deliveries and Infants Served by Title V and Entitled to
Benefits Under Title XIX 75
State MCH Toll-Free Telephone Line Data 77
Title V Maternal & Child Health Services Block Grant State
Profile for FY__ 79
Tracking Performance Measures 82

PERFORMANCE/OUTCOME MEASURES DETAIL SHEETS AND

FORMS 12 – 21 91

[States will add their State Performance Measure/Outcome Measure Detail

Sheets after the National ones]

National Performance Measures Detail Sheets 91

Tracking Health Outcome Measures 113

National Outcome Measures Detail Sheets 117
State Outcome Measure Detail Sheet 126

Characteristics Documenting Family Participation in
CSHCN Programs 128
List of MCH Priority Needs 130
Technical Assistance (TA) Planning 131
State Performance/Outcome Measure Detail Sheet 136
Health Systems Capacity Indicators – Forms for HSCI 01 through 04, 07A, 07B & 08 – Multi-Year Data 138
Health Systems Capacity Indicator Reporting Form –
HSCI 05 & 06 142
Health Systems Capacity Indicator Reporting and Tracking Form – HSCI 09A & 09B 144

Health Systems Capacity Indicators Detail Sheets 148

Form 20 - Health Status Indicators #01- #05 – Multi-Year Data 162

Form 21 - Health Status Indicators Demographic Data - #06 - #12 168

E. Health Status Indicators Detail Sheets 178

GLOSSARY 199

TECHNICAL NOTE: GUIDELINES FOR CALCULATING PERFORMANCE MEASURES USING SMALL SAMPLES 211

STATE SUPPORTING DOCUMENTS 215

A. Organizational Charts 215

B. Other State Supporting Documents 215

PART ONE

BACKGROUND AND ADMINISTRATIVE INFORMATION

HISTORY AND PURPOSE

The Maternal and Child Health Bureau

The Maternal and Child Health Bureau (MCHB) is the principal focus within Health Resources and Services Administration (HRSA) for all Maternal and Child Health (MCH) activities within the Department of Health and Human Services (DHHS). MCHB’s mission is to provide National leadership through working in partnership with States, communities, public/private partners, tribal entities and families, to strengthen the MCH infrastructure, and to build knowledge and human resources. Its mission also includes ensuring continued improvement in the health, safety, and well-being of the MCH population. To achieve its mission, MCHB directs resources towards a combination of direct health care services, enabling services, population-based services, and infrastructure or resource-building activities. Within MCHB the Division of State and Community Health (DSCH) has the administrative responsibility for the Title V MCH Services Block Grant to States Program. DSCH is committed to being the Bureau’s main line of communication with States and communities, in order to consult and work closely with both of these groups and others interested in providing a wide range of MCH programs and developing community-based service systems.

Note: The terms “States” and “a State” seen throughout the document refer to all 50 States and 9 jurisdictions.

Maternal and Child Health Services Block Grant (Title V)

Since its original authorization in 1935, Title V of the Social Security Act has been amended several times to reflect the increasing National interest in maternal and child health and well-being. One of the first changes occurred when Title V converted to a block grant program as part of the Omnibus Budget Reconciliation Act (OBRA) of 1981. This change resulted in the consolidation of seven categorical programs into a single block grant. These programs included: Maternal and Child Health and services for Children with Special Health Care Needs (Title V of the Social Security Act); supplemental security income for children with disabilities (sec. 1651(c) of the Social Security Act); lead-based paint poisoning prevention programs (sec. 316 of the Public Health Service (PHS) Act); genetic disease programs (sec. 101 of the PHS Act); sudden infant death syndrome programs (sec. 1121 of the PHS Act); hemophilia treatment centers (sec. 1131 of the PHS Act); and adolescent pregnancy grants (Public Law PL 95-626).

Another significant change was contained in the Omnibus Budget Reconciliation Act (OBRA) of 1989 which specified new requirements for accountability. These amendments enacted under OBRA introduced stricter requirements for the use of Federal funds and for State planning and reporting. Congress sought to balance the flexibility of the block grant with greater accountability, by requiring State Title V programs to report progress on key MCH indicators and other program information. Thus, the block grant legislation emphasizes accountability while providing States with appropriate flexibility to respond to MCH needs and to develop solutions. This theme of assisting States in the design and implementation of MCH programs to meet local needs, while at the same time asking them to account for the use of Federal/State funds, was embodied in the requirements contained in guidance documents for block grant Application/Annual Reports. In 1996, the MCHB began a process of programmatic assessments and planning activities aimed at improving those guidance documents.

In 1993 the Government Performance and Results Act (GPRA), Public Law 103-62, required Federal agencies to establish measurable goals that could be reported as part of the budgetary process. For the first time, funding decisions were linked directly with performance. Among its purposes, GPRA is intended to “...improve Federal program effectiveness and public accountability by promoting a new focus on results, service quality, and customer satisfaction.” GPRA requires each Federal agency to develop comprehensive strategic plans, annual performance plans with measurable goals and objectives, and annual reports on actual performance compared to performance goals. The MCHB effort to respond to GPRA requirements coincided with other planned improvements to the block grant guidance. As a result, the block grant Application/Annual Report and forms contained in the 1997 edition of the Maternal and Child Health Services Title V Block Grant Program - Guidance and Forms for the Title V Application/Annual Report served two purposes: a) to ensure that the States and jurisdictions could clearly, concisely, and b) accurately tell their MCH “stories.” This Application/Annual Report became the basis by which MCHB met its GPRA Block Grant to States program reporting requirements.

Another significant milestone was the development in 1996 of an information system. The Title V MCH Services Block Grant to States Program Application/Annual Report, submitted by all States, contains a wealth of information concerning various State MCH initiatives, State-supported programs, and other State-based responses designed to address their MCH needs. In order to better utilize the data contained in the Application/Annual Report, MCHB developed an electronic information system, the Title V Information System (TVIS), designed to capture data contained in the Application/Annual Report. The system, initially designed to capture the qualitative programmatic information collected by the States, was modified according to MCHB’s performance measurement model to additionally collect quantitative data. This joint development of the Guidance and the database enabled the TVIS to become a powerful and useful tool for a number of audiences. The TVIS is available to the public on the World Wide Web at:

https://perfdata.hrsa.gov/mchb/TVISReports/Default.apsx.

As the chief financial foundation and the primary legislative authorization for the MCHB, Title V provides 80% of the funding sources for all Bureau programs. Under Title V, MCHB administers a Block Grant and competitive Discretionary Grants. The purpose of the Title V MCH Services Block Grant Program is to create Federal/State partnerships in all 59 States to develop service systems to meet MCH challenges which include the following:

Significantly reducing infant mortality;
Providing comprehensive care for all women before, during, and after pregnancy and childbirth;
Providing preventive and primary care services for infants, children, and adolescents;
Providing comprehensive care for children and adolescents with special health care needs;
Immunizing all children;
Reducing adolescent pregnancy;
Preventing injury and violence;
Putting into community practice National standards and guidelines for prenatal care, for healthy and safe child care, and for the health supervision of infants, children, and adolescents;
Assuring access to care for all mothers and children; and
Meeting the nutritional and developmental needs of mothers, children and families.

Under Title V, MCHB also administers two types of Federal Discretionary Grants, Community Integrated Service Systems (CISS) grants and Special Projects of Regional and National Significance (SPRANS). The CISS set-aside designates appropriations for programs to reduce infant mortality and improve the health of mothers, pregnant women, and children through the development and expansion of community integrated service systems. These systems are public-private partnerships of health-related and other relevant organizations and individuals collaborating to use community resources to address community-identified health problems.

The Community Integrated Service System (CISS) program seeks to improve the health of mothers and children through discretionary grant support for the development and expansion of community integrated service systems. These systems are public/private partnerships of health-related and other relevant organizations and individuals working collaboratively to use community resources to address the health of children in the context of their family in a comprehensive way. This program aims to support the health of children in all aspects of their physical, social, and emotional development.

A percentage of Title V funds are also set aside for a variety of SPRANS grants. SPRANS activities include:

MCH research;
MCH training;
Genetic disease testing, counseling, and information dissemination;
Hemophilia diagnostic and treatment centers; and
MCH improvement projects that support a broad range of innovative strategies.

MCHB also administers the following categorical programs:

Emergency Medical Services for Children;
Traumatic Brain Injury;
Healthy Start Initiative;
Universal Newborn Hearing Screening
Autism; and
Home Visiting Program

As the Bureau considers the life course approach in its strategic planning, some States have also begun to utilize the life course model as an organizing framework for addressing the MCH needs in their States. The life course approach points to broad social, economic, and environmental factors as underlying contributors to health and social outcomes. It also focuses on persistent inequalities in health and well-being of individuals. The interplay of risk and protective factors at critical points of time influence health throughout all of one’s life.

The socio-ecological framework emphasizes that children develop within families, families exist within a community, and the community is surrounded by the larger society. These systems interact with and influence each other to either decrease or increase risk factors or protective factors that affect a range of health and social outcomes.

The life course approach and socio-ecological frameworks highlight the importance of positive interventions at sensitive developmental periods and address social and environmental determinants critical in improving outcomes and reducing health disparities.

Throughout its illustrious 75 year history, the Title V MCH Services Block Grant to States Program has sought to fulfill its intent of improving the health of all mothers and children consistent with the applicable health status goals and National health objectives. This brief history has provided a few highlights of that legacy under Title V.

II. LEGISLATIVE REQUIREMENTS

A. Who Can Apply for Funds [Section 505(a)]

The Application/Annual Report shall be developed by, or in consultation with, the State maternal and child health agency and shall be made public within the State in such manner as to facilitate comment from any person (including any Federal or other public agency) during its development and after its transmittal.

B. Use of Allotment Funds [Section 504]

The State may use its Title V MCH Services Block Grant funds for the provision of health services and related activities (including planning, administration, education, and evaluation) consistent with its application. In addition, the State may request supplemental funds from the Bureau to support identified technical assistance needs. Related to technical assistance, the State should plan for and allot funds for the MCH and Children with Special Health Care Needs (CSHCN) Directors to attend two meetings each year in person. One of these meetings is the required Block Grant Application/Annual Report review that is held at a site designated annually by DSCH. The second is the Partnership Meeting which aims to: 1) update State MCH and CSHCN Directors on relevant legislation and MCHB initiatives; 2) convene leaders, disseminate best practices and share innovations in the field of MCH, and 3) provide opportunities for information exchange, networking, and collaboration among States and with MCHB.

Funds may not be used for cash payments to intended recipients of health services or for purchase of land, buildings, or major medical equipment. Other restrictions apply as specified in Section 504(b).

C. Application for Block Grant Funds [Section 505]

Each State is required to conduct a statewide Needs Assessment every 5 years. The result of that Needs Assessment and any updates are submitted in the interim years in the Application/Annual Report. The Application/Annual Report will contain information that is consistent with the health status goals and National health objectives regarding the need for:

preventive and primary care services for all pregnant women, mothers, and infants up to age one;
preventive and primary care services for children;
services for CSHCN [as specified in section 501(a)(1)(D) "family-centered, community-based, coordinated care (including care coordination services) for children with special health care needs (CSHCN) and to facilitate the development of community-based systems of services for such children and their families"];

and includes for each fiscal year:

a plan for meeting the needs identified by the statewide assessment; and
a description of how the funds allotted to the State will be used for the provision and coordination of services to carry out the MCH program.

At least thirty percent (30%) of Federal Title V funds must be used for preventive and primary care services for children and at least thirty percent (30%) for services for CSHCN as specified in Section 501 (a)(1)(D). Such services include providing and promoting family-centered, community-based, coordinated care (including care coordination services) for CSHCN and facilitating the development of community-based systems of services for such children and their families. The thirty percent (30%) requirement may be waived as specified in Section 505(b)(1-2). A request for waiver must be included in the application letter of transmittal. In addition, of the amount paid to a State under Section 503 from an allotment for a fiscal year under Section 502(c), not more than ten percent (10%) may be used for administering the funds paid under this section.

The State must maintain the level of funds being provided solely by such State’s MCH programs at the level provided in fiscal year 1989. [Section 505(a)(4)].

Other requirements for allocating funds, charging for services, a toll-free hotline, and coordination of services with other programs are found in Section 505.

D. Annual Report [Section 506]

An Annual Report must be submitted to the MCHB each year in order to evaluate and compare the performance of different States assisted under this Title and to assure the proper expenditure of funds. The Annual Report will include a description of program activities, a complete record of the purposes for which funds were spent, the extent to which the State has met the goals and objectives it set forth, as well as the National health objectives, and the extent to which funds were expended consistent with the State's application. The standardized format of the Annual Report allows for consistency in reporting and facilitates the preparation of the report to congress, as required in [Section 506(a)(3)].

As required in Section 509(a)(5), the MCHB has made a substantial effort not to duplicate other Federal data collection efforts. In partnership with the States, only MCH data necessary to fulfill the requirements of Title V which are not available at the National level, or may be more timely from the State, or are required for tracking performance measures, are requested as part of the Annual Report. Data are not available from the National Center for Health Statistics (NCHS) or other Federal sources for the Marshall Islands, Federated States of Micronesia, Republic of Palau, Commonwealth of the Northern Mariana Islands, and American Samoa. These jurisdictions must report their own vital statistics and health data using general instructions from the NCHS.

All the elements that are statutorily required for an Annual Report are located in PART TWO (Sections I, III, IV, V, VI).

E. Administration of Federal and State Programs [Section 509]

MCHB in HRSA is the organizational unit responsible for the administration of Title V. Within the Bureau, DSCH has responsibility for the day-to-day operation of the Title V MCH Services Block Grant to States Program. Applicants may obtain additional information regarding administrative, technical and program issues concerning the Block Grant Application/Annual Report by contacting:

Division of State and Community Health

Maternal and Child Health Bureau

Health Resources and Services Administration

5600 Fishers Lane, Room 18-31

Rockville, Maryland 20857

Telephone: (301) 443-2204

Fax: (301) 443-9354

Within each State, the State Health Agency is responsible for the administration (or supervision of the administration) of programs carried out with Title V allotments.

III. BLOCK GRANT APPLICATION/ANNUAL REPORT PREPARATION AND SUBMISSION

A. Deadline for Application/Annual Report

The Application/Annual Report is due by close of business on July 15 of each year unless States are otherwise notified.

B. Electronic Submission

The Title V Application/Annual Report is completed electronically. The annual application, available to the States via the Web includes a copy of this Guidance, a copy of the Title V law, narrative outlines with required tables, forms, and diagrams. It also includes tools to assist the States in assessing the completeness of their applications as they are being prepared and alerts to help reduce data entry errors and to help ensure data validity.

States identify those individuals that will have access to the electronic applications. These users access the system through use of a user name and password. HRSA’s Electronic Handbook (EHB) serves as a portal to allow access to the Web-based application and serves as an authentication of the Block Grant Applicant. States will receive detailed information from MCHB about these registration, log-on and submission procedures prior to the opening of the system for access. When technical assistance is needed with the preparation and submission of the Application/Annual Report, the HRSA Call Center is available. The Call Center can be contacted at 1-877-Go4-HRSA (877-464-4772) or at [email protected].

C. General Information on Preparation and Submission

The electronic Application/Annual Report format for the Block Grant described in this document enables data on each State’s needs, priorities, program activities, and performance and outcomes measures to be compiled and shared with other States and the public. The Title V Information System (TVIS) has been developed to capture information from States’ Block Grant Application/Annual Report. This relational database system is open to the public and allows easier and more accurate access to information such as State Performance Measures, financial and program data, etc. It is important, therefore, that States be as accurate as possible with their data and follow carefully the organization and formatting instructions in the online system.

States complete electronic versions of the forms in this guidance in the Web-based Title V Application/Annual Report.

A Glossary of Terms is presented in Part Two, Section VIII. Definitions for most of the significant words, terms, and phrases used on the various forms in the Application/Annual Report are listed. Differences in the State’s definitions for programs, services, or other elements as compared to those presented in the glossary should be clarified in the narrative of the Application/Annual Report.

The Application/Annual Report must be concise, accurate, and complete in addressing the minimum requirements of both Title V and this Guidance. All necessary formatting in the electronic Title V Application has been determined by MCHB and will be included in the annual Application/Annual Report Guidance that is provided.

The narrative sections of the Application/Annual Report have character length limitations enforced by the electronic system. These length limits are identified at the top of each section within the online system. For ease of writing within the character limits, States should compose the narrative in a word processing package of their choice. Then cut and paste each section from the document into the appropriate section in the online system. These length limitations do not apply to a State’s Needs Assessment, which is a stand-alone document.

The narrative is to be composed of text only, using standard characters. Embedding charts, tables or graphs in the narrative is not possible. Use of special characters, such as bullets, is not permitted.

For every year after the first in a five year cycle, leave all of the previous year’s narrative text in place. Where changes of any kind (additions, corrections, updates, and revisions) are needed, keep the existing text, add the new text, and use the application’s tool for adding the /2013/ . . . . .//2013// nomenclature. This coding will automatically change the appearance of the new text so it can be easily distinguished from the prior year’s text.

To add the new text nomenclature: Begin with the first character of the new text and highlight all the new text. Next, click on the hyperlink labeled “Identify Text as an Update.” This link appears below the “”General Requirements header and across from the button “View Last Year’s Narrative.” The text will automatically be enclosed in the /2013/ . . . //2013// nomenclature.

The following is a short illustration of how this will appear (on the View version of the online application):

[From the 2013 Application]: The Program Director of the State Maternal and Child Health Program is Dr. Jane Doe. Dr. Doe reports to the Director of the State Department of Health.

/2013/ Dr. Doe moved to a new program in December. The new Director of the State Maternal and Child Health Program is Dr. John Smith. New organizational lines of authority have Dr. Smith reporting directly to the Governor.//2013//

If further changes are required in subsequent years, use the same procedure. Leave the previous years’ narrative changes in place, and use the application’s tool for adding the /2013/ . . . . .//2013// nomenclature for any new text. (Once the entries are saved, the system will automatically bold and italicize text between the brackets on the view version.) To continue the illustration, it would look as follows:

[From the 2014 Application]: The Program Director of the State Maternal and Child Health Program is Dr. Jane Doe. Dr. Doe reports to the Director of the State Department of Health.

/2013/ Dr. Doe moved to a new program in December. The new Director of the State Maternal and Child Health Program is Dr. John Smith. New organizational lines of authority have Dr. Smith reporting directly to the Governor.//2013//

/2014/ Dr. Smith remains the Director of the MCH program but that position once again reports to the Director of the State Department of Health.//2014//

This procedure allows for rapid determination of differences from year to year without the need to find previous years’ applications and compare narratives in order to discover exactly what changes have been made.

Since the text of the performance measures changes each year and does not retain the previous year’s narrative, the use of the “/Application Year/” update is not necessary in narrative sections addressing performance measures.

States may attach one document per narrative section to further illustrate that section. This attachment is not to be a continuation of the narrative for that section. This allows a State to provide charts, graphs, and tables that cannot be included in the narrative, which must be combined into one attachment for each narrative section. The filename for an attachment should not exceed 35 characters in length, and the maximum file size allowed for each attachment is 10MB.

Other documents, including any letters of support, may be formulated into a single list which is included in the application with a statement that the actual items are available upon request in the State MCH office.

As required in Section 509(a)(5), the MCHB has made a substantial effort not to duplicate other Federal data collection efforts. In partnership with the States, only maternal and child health data necessary to fulfill the requirements of Title V which are not available at the National level or may be more timely from the State or required for tracking performance measures, will be gathered to meet reporting requirements. Data are not available from National Center for Health Statistics or other Federal sources for the Marshall Islands, Federated States of Micronesia, Republic of Palau, Commonwealth of the Northern Mariana Islands, and American Samoa. These jurisdictions must report their own vital statistics and health data using general instructions from the National Center for Health Statistics.

Since the MCHB production of Annual Reports will be an extraction process it is critical for their development that States carefully follow the general instructions for completing the forms and the specific instructions included with each form. Please refer to the instructions link on the top right of every online form in the Title V Information System.

APPLICATION REVIEW PROCESS

Each State is required to submit an annual Title V MCH Services Block Grant to States Program Application/Annual Report. All applications are submitted to HRSA via the EHB. The web-based application will ensure completeness of the data. All complete applications are submitted to a standardized review process by MCHB staff and other experts in MCH, including families and consumers of the MCH population. Present at the review are the State MCH/CSHCN leadership and representation from the Federal MCHB staff for an in-depth discussion of the Application/Annual Report and the State’s plan for the coming year. These reviews are conducted in a face to face format. The focus of the review is on the progress being made by each State in meeting its goals in the National and State Performance Measures, and what type(s) of technical assistance may be needed in order for the State to move towards achieving these goals. In addition, the face to face review includes a detailed discussion on the major financial, policy, and legislative actions that will affect the State’s program in the coming year.

PART TWO

INSTRUCTIONS FOR COMPLETING THE APPLICATION/ANNUAL REPORT

In an ongoing effort to improve the application process for States, revisions have been made in this new edition of the Guidance. The revisions are as follows:

PART TWO, Section II, Part A. Needs Assessment Process--Background and Conceptual Framework: Instructions on the completion of the 5-Year Statewide Needs Assessment have been eliminated from this edition as the full Needs Assessment is not a task during the period for which this application guidance is approved; instructions describe the methods used during interim years to update and address the Needs Assessment findings.

PART TWO, Section III, Part F. Health Systems Capacity Indicators (HSCIs). Reporting requirements for the HSCI have been changed to allow States to update the narrative discussion and data analysis only for those indicators that best inform their future program planning efforts.

PART TWO, Section IV, Part E. Health Status Indicators (HSIs). Reporting requirements for the HSIs have been changed to allow States to update the narrative discussion and data analysis only for those indicators that best inform their future program planning efforts.

Form 7 – Number of Individuals Served Under Title V. The Number of Individuals served has been clarified to assist States in more accurately estimating the number of individuals who receive Title V services.

Form 10 – Title V Maternal and Child Health Services Block Grant State Profile. Instruction on including, as an option, a State Family or Youth Leader has been added.

Detail sheets for the Performance Measures, Health Systems Capacity Indicators, and Health Status Indicators have been updated with corresponding Healthy People 2020 Objectives.

The application kit that is provided annually to the States via the Web includes a copy of the Application Guidance, a copy of the Title V law, and all required tables, forms, and diagrams.

I – GENERAL REQUIREMENTS

Letter of Transmittal

An electronic letter of transmittal from the responsible State health agency official must be the first page of the Application/Annual Report. The letter must also contain the documentation for waiver of a 30 percent allotment if the State is so requesting. The letter of transmittal is attached in the Title V Application to Section IA.

Face Sheet

Each section of the Application Face Sheet (Standard Form 424) must be completed and submitted electronically along with the rest of the Application/Annual Report. Procedures for authentication of the Block Grant applicant will be sent to each State.

Assurances and Certifications

The appropriate Assurances and Certifications--non-construction program, debarment and suspension, drug free work place, lobbying, program fraud, and tobacco smoke--that accompany this guidance are to be maintained on file in the State’s MCH program’s central office. They may be attached to this section but this is not required. Instead, provide either the URL to access these assurances or provide information as to where and how the assurances and certifications can be made available.

Table of Contents

The Table of Contents is automatically generated by the system, and conforms to the headings in Parts One and Two on pages seven to nine of the Guidance.

Public Input [Section 505(a)]

Describe the process by which the State will make this application public to facilitate comment from any person during its development and after its transmittal. This includes not only illustrating how it facilitated or provided opportunities for the public to provide ideas, comments, or concerns about needs or programs, as well as how it facilitated or provided the opportunity for the public to comment on the application. If applicable, the State may describe how the public input received was used in program planning and/or the application.

Some activities are linked specifically to the application process. Such activities may include:

Public Hearings
Advisory Council Review
Web Posting
Public Notices
Other Use of Media
Outreach to Specific Stakeholders

States also have regular mechanisms in place to obtain input and feedback on their programs. Such methods include advisory groups and task forces addressing specific programs or issues. Many, if not most States, have mechanisms in place to obtain regular and ongoing input from parents, especially parents of CSHCN. Some States engage youth directly in planning programs and developing materials in areas such as suicide prevention. If applicable, these mechanisms should also be described.

Further information regarding public input can be found by opening the section titled “Technical Assistance to States” on the MCHB website, http://www.mchb.hrsa.gov. See the resource document entitled, “Facilitating Public Comment on the Title V MCH Block Grant.”

II – NEEDS ASSESSMENT

A. Needs Assessment—Background and Conceptual Framework

Title V legislation requires that the State prepare a statewide Needs Assessment every five (5) years that shall identify (consistent with health status goals and National health objectives) the need for:

preventive and primary care services for all pregnant women, mothers and infants up to age one;
preventive and primary care services for all children; and
services for CSHCN. [Section 505 (a)(1)].

The next 5-Year Statewide Needs Assessment will be submitted in calendar year 2015 as an attachment in the electronic application system. It is intended to function for the State as a stand-alone document. States will only have the ability to upload the 5-Year Statewide Needs Assessment document into the Title V Information System during the Needs Assessment reporting year.

This application guidance will only address what is required for the Needs Assessment in the interim year since the next 5-Year Statewide Needs Assessment will not be submitted during the period for which this application guidance is approved (Month Day , 2012 through Month Day, 2015). The instructions for how to structure the 5-Year Statewide Needs Assessment document is archived at: https://perfdata.hrsa.gov/MCHB/TVISReports/default.aspx. They will be included again in the next MCH Block Grant guidance.

An overview of the MCH Needs Assessment process and its relationship with planning and monitoring functions is presented in Figure 2 on page 31.

Improved Outcomes and Strengthened Partnerships: Figure 2 reflects the expectation that following the ten identified steps of the Needs Assessment process, as described below, will result in two ultimate goals: (1) improved outcomes for MCH populations and (2) strengthened partnerships. The strengthened partnerships should include, but are not limited to, collaboration efforts with the Federal MCHB, State Department of Health, other agencies and organizations within each State that have an interest in the wellbeing of the MCH population, families, practitioners, and the community.

The following is a brief description of the steps involved in the Needs Assessment process.

1. Engage Stakeholders

As depicted in Figure 2, the starting point is to engage stakeholders. Engaging stakeholders and strengthening partnerships is a continuous and on-going activity. The State needs strong partnerships with its stakeholders throughout the Needs Assessment process. Effective coalitions can help the State realistically assess needs and identify desired outcomes and mandates, assess strengths and examine capacity, select priorities, seek resources, set performance objectives, develop an action plan, allocate resources, and monitor progress for impact on outcomes.

2. Assess Needs and Identify Desired Outcomes and Mandates

The second stage in the process is to assess needs of the MCH population groups using Title V indicators, performance measures and other quantitative and qualitative data available in the State. The MCH population groups identified in Section 505(a)(1) of the statute are: pregnant women, mothers, and infants; children; and children with special health care needs. The anticipated outcome is to identify the community/system needs and desired outcomes by specific MCH population group. In addition, the State will need to identify legislative, political, community-driven, financial, or other internal and external mandates that they will be required to implement, regardless of what the Needs Assessment reveals.

3. Examine Strengths and Capacity

The third stage in the process is examining strengths and capacity. This stage involves examining the State’s capacity to engage in various activities, including conducting the 5-Year Statewide Needs Assessment and collecting annual performance data, and to provide services by each pyramid level. The pyramid appears on page 5. This stage involves describing and assessing the State’s current resources, activities, and services as well as the State’s ability to continue to provide quality services by each of the pyramid levels. These levels include direct health care services, enabling services, population-based services, and infrastructure-building services. The anticipated outcome is a better understanding of the relationship of existing program/system capacity to identified strengths and needs for each State. This examination may reveal strengths and weaknesses in capacity not previously identified.

4. Select Priorities

In the select priorities stage, each State examines the needs identified and matches those needs to desired outcomes, required mandates, and level of existing capacity. Based on the results of this process, the State then selects its most important or highest priority, MCH strengths and needs to receive targeted efforts for improvement and/or continuation of progress. The inputs include: the Needs Assessment, the opinions of stakeholders, the examination of capacity, and the political priorities within the State. The anticipated outcome is development of a set of priority needs unique to each individual State based on Needs Assessment findings. Mandated activities are understood as continuing. Priorities identified should address areas in which the State believes there is reasonable opportunity for a focused programmatic effort (for example, new or enhanced interventions, initiatives, or systems of care) to lead to an improved outcome.

Seek Resources

Depending upon the priorities selected and existing resources identified, the State may need to seek additional resources, funds, or authority from the State legislature or funding agencies in order to address priority areas.

6. Set Performance Objectives

Setting performance objectives consists of two phases. First, each State will select seven to ten State-negotiated Performance Measures to assess progress on State priorities not already monitored through National Performance and Outcome Measures. Next, each State will set Outcome Measure targets and State and National Performance Measure targets. The anticipated result is the identification of State-negotiated Performance Measures and Performance Measure targets.

7. Develop an Action Plan

The next stage is to develop an action plan, which includes identifying activities to address priority strengths and needs. This stage involves describing the activities that have been identified by the four pyramid levels: direct health care services, enabling services, population-based services, and infrastructure building services.

Allocate Resources

Following the identification of activities is the allocation of resources stage. In this stage, the focus is on the funding of planned activities to address State priorities. The inputs include the action plan, current budgets, political priorities, and partnerships. The anticipated outcome is the development of a budget that directs available resources towards activities that have been identified in Stage Seven as most important for addressing the State’s priorities.

Monitor Progress for Impact on Outcomes

In monitoring progress for impact on outcomes, the States examine the results of their efforts to see if there has been improvement. The inputs include the State Performance Measures, National Performance Measures, Outcome Measures, Health Status Indicators, Health System Capacity Indicators, performance objectives, and other quantitative and qualitative information. Potential outcomes may include altered activities and shifting of resource allocations to address current levels of performance and the availability of resources. Feedback loops between various stages of the process allow for continuous input and re-evaluation of the outputs.

Report Back to Stakeholders

This final step assures accountability to the stakeholders and partners who have worked with the MCH staff throughout the Needs Assessment process. It also assures the continued involvement of all stakeholders and partners in the ongoing Needs Assessment process.

B. Needs Assessment Summary Update: Interim Years

During any interim year when a 5-Year Statewide Needs Assessment is not due, it is equally important that the State continue to refer to the Needs Assessment findings and monitor progress toward addressing the State’s priority needs. As populations change, new trends emerge, system capacity shifts, etc. it is critical the State engage in selected steps of the Needs Assessment process on a regular basis.

In Section II.C of the web-based application, States must provide an update on their activities related to the Needs Assessment process that were conducted during the interim year. The update to the Needs Assessment Summary should include a discussion of the following:

Any changes in the population strengths and needs in the State priorities since the last Block Grant application.

Any changes in the State MCH program or system capacity in those State priorities since the last Block Grant application.

A brief description of any activities undertaken to operationalize the 5-Year Statewide Needs Assessment, such as: 1) ensuring that the State addresses the findings and recommendations resulting from the Needs Assessment, 2) monitoring the timelines of the action plans, 3) reporting by a designated person or group responsible for accountability, and 4) linking the Needs Assessment process back into State program planning.

A brief description of ongoing activities to gather information from the community and to evaluate implementation of the 5-Year Statewide Needs Assessment. Examples of these activities include: data collection and analysis, key informant interviews, public forums, establishing an advisory group, and surveys. It is important to gather input from general community members as well as providers and community leaders.

F igure 2. State Title V MCH Program

Needs Assessment, Planning, Implementation

& Monitoring Process

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III - STATE OVERVIEW

A. Overview of the State

This section should put into context the Title V program within the State’s health care delivery environment. Discuss the principal characteristics important to understanding the health needs of the entire State's population. Describe the State health agency's current priorities or initiatives and the resulting Title V program's roles and responsibilities.

This overview should include a description of the process used by the Title V administrator to determine the importance, magnitude, value, and priority of competing factors impacting health services delivery in the State including the current and emerging issues and how these are taken into consideration as well.

Include in this description the extent to which poverty, racial and ethnic disparities in health status, geography, urbanization, and the private sector create unique challenges for the delivery of Title V services.

B. Agency Capacity

Describe in this section the State Title V agency's capacity to promote and protect the health of all mothers and children, including CSHCN.

State MCH and CSHCN Programs have taken steps to ensure a statewide system of services that reflect the principles of comprehensive, community-based, coordinated, family-centered care which are essential for effectively fostering and facilitating activities. Describe the extent to which the following occur:

State program collaboration with other State agencies and private organizations;
State support for communities;
Coordination with health components of community-based systems; and
Coordination of health services with other services at the community level.

Describe State statutes relevant to Title V program authority and how they impact upon the Title V program.

Provide a description of the State’s Title V capacity to provide:

preventive and primary care services for all pregnant women, mothers and infants;
preventive and primary care services for all children;
services for CSHCN [Section 505(a)(1)], including the capacity:
1. to provide rehabilitation services for blind and disabled individuals under the age of 16 receiving benefits under Title XVI (the Supplemental Security Income Program), to the extent medical assistance for such services is not provided under Title XIX (Medicaid);
2. to provide and promote family-centered, community-based, coordinated care including care coordination services, for CSHCN and facilitate the development of community based systems of services for such children and their families; and,

culturally competent care that is appropriate to the State’s MCH populations.

Provide examples of the mechanisms that have been developed to have culturally competent approaches to service delivery. Examples of such activities can include:

Collect and analyze data according to different cultural groups (e.g. race, ethnicity, language) and use the data to inform program development and service delivery.

Ensure the provision of training, both in orientation and ongoing professional development, for staff, family leaders, volunteers, contractors and subcontractors in the area of cultural and linguistic competence.

Collaborate with informal community leaders/groups (e.g. natural networks, informal leaders, spiritual leaders, ethnic media, family advocacy groups) and families of culturally diverse groups in needs/assets assessments, program planning, service delivery and evaluation/monitoring/quality improvement activities.

Have in place allocation of resources that adequately meet the unique access, informational and service needs of culturally diverse groups.

Performance standards for staff and contractors which incorporate cultural competence practices/policies.

Provide policies and guidelines that support the above items.

C. Organizational Structure

Describe the organizational structure and placement of the Governor, State health agency, the MCH and CSHCN programs in the State government. Official and dated organizational charts that include all program elements of the Title V program, clearly depicted, should be on file in the State office and available upon request at the time of the Block Grant review. Describe concisely how the State health agency is "responsible for the administration (or supervision of the administration) of programs carried out with allotments under Title V" [Section 509(b)]. All programs funded by the Federal-State Block Grant Partnership budget total (Form 2, Line 8) should be included. An organizational chart is a required attachment to Section III.C.

D. Other (MCH) Capacity

Describe the number and location (central and out-stationed) of staff who work on Title V programs. Include staff who provide planning, evaluation, and data analysis capabilities. Include the qualifications, in the form of a brief biography, of senior level management employees in lead MCH-related positions. Also include the number of and role for parents of children with special health care needs on staff. In addition, States are encouraged to provide other MCH workforce information that may be available, such as full time equivalents (FTEs) at the State and local levels, tenure of the State MCH workforce, and projected changes to the MCH workforce in the coming year.

E. State Agency Coordination

Describe the relevant organizational relationships among the State Human Services agencies (e.g., public health, mental health, social services/child welfare, education, corrections, Medicaid, CHIP, Social Security Administration, Vocational Rehabilitation, disability determination unit, alcohol and substance abuse, rehabilitation services).

Describe the relationship of the State to Tribes, Tribal Organizations and Urban Indian Organizations; and local public health agencies (including city MCH programs).

Describe the relationship with federally qualified health centers; primary care associations; tertiary care facilities; and available technical resources such as public health and health professional educational programs and universities, all of which may enhance the capacity of the Title V program.

In this section also describe the plan for coordination of the Title V program with (1) the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT), (2) other federal grant programs (including WIC, related education programs, and other health, developmental disability, and family planning programs), and (3) providers of services to identify pregnant women and infants who are eligible for Title XIX and to assist them in applying for services [Section 505(a)(5)(F)]. Also discuss coordination with the Social Security Administration, State Disabilities Determination Services unit, Vocational Rehabilitation, and family leadership and support programs.

F. Health Systems Capacity Indicators

The Health Systems Capacity Indicators (HSCIs) inform States about their ability to assure access to Maternal and Child Health (MCH) policy and program relevant information. The indicators serve as a surveillance monitoring tool and provide information on the State’s capacity to impact health outcomes.

States should thoughtfully examine their indicators on an ongoing basis and look for trends across the MCH health system.

The indicator data for all nine Health Systems Capacity Indicators (HSCIs) are documented annually on Forms 17, 18, and 19. The State Title V agency may choose one, some, or all of the most relevant indicators to discuss in the narrative section. Within the 9 HSCI narrative sections describe those indicators that best inform the State’s future Program planning efforts. If applicable, describe the data source(s). In the HSCI narrative section, States may also choose to describe such items as:

What do the Health Systems Capacity Indicators show? (trend analysis)
Which trends or indicators are most critical or sentinel to your work? (prioritizing)
For relevant indicators, what is your desired outcome? (evaluation)
Based on the trend analysis/prioritized indicators what programming or policy changes are needed for the desired impact? (quality improvement)

SUMMARY OF HEALTH SYSTEMS CAPACITY INDICATORS

Reported Annually

#01 HEALTH SYSTEMS CAPACITY INDICATOR

The rate of children hospitalized for asthma (ICD-9 Codes: 493.0 – 493.9) per 10,000 children less than five years of age.

#02 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of Medicaid enrollees whose age is less than one year who received at least one initial periodic screen.

#03 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of Children’s Health Insurance Program (CHIP) enrollees whose age is less than one year who received at least one periodic screen.

#04 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of women (15 through 44) with a live birth during the reporting year whose observed to expected prenatal visits are greater than or equal to 80 percent on the Kotelchuck Index.

#05 HEALTH SYSTEMS CAPACITY INDICATOR

Comparison of health system capacity indicators for Medicaid, non-Medicaid, and all MCH populations in the State

#06 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of poverty level for eligibility in the State’s Medicaid and CHIP programs for infants (0 to 1), children, and pregnant women.

#07A HEALTH SYSTEMS CAPACITY INDICATOR

The percent of potentially Medicaid eligible children who have received a service paid by the Medicaid Program.

(Formerly National Performance Measure #14)

#07B HEALTH SYSTEMS CAPACITY INDICATOR

The percent of EPSDT eligible children aged 6 through 9 years who have received any dental services during the year.

#08 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of State SSI beneficiaries less than 16 years old receiving rehabilitative services from the State Children with Special Health Care Needs Program.”

#09(A) HEALTH SYSTEMS CAPACITY INDICATOR

The ability of States to assure that the Maternal and Child Health program and Title V agency have access to policy and program relevant information and data.

#09(B) HEALTH SYSTEMS CAPACITY INDICATOR

The ability of States to determine the percent of adolescents in grades 9 through 12 who report using tobacco products in the past month.

IV - PRIORITIES, PERFORMANCE AND PROGRAM ACTIVITIES

APPLICATION/ANNUAL REPORT

A. Background and Overview

The Government Performance and Results Act (GPRA – Public Law 103-62) requires each Federal agency to establish performance measures that can be reported as part of the budgetary process that links funding decisions with performance and related outcome measures to see if there were improved outcomes for target populations.

Since 1999 MCHB has included performance plans and performance information in its budget submission. MCHB must submit annual reports to Congress on the actual performance achieved compared to that proposed in the performance plan. This section of the guidance describes how the Federal – State partnership will implement these performance reporting requirements. Figure 3, on the following page, “Title V Block Grant Performance Measurement System” presents a schematic of a system approach that begins with the Needs Assessment and identification of priorities and culminates in improved outcomes for the Title V population. After each State establishes a set of priority needs from the 5-Year Statewide Needs Assessment, programs are designed, assigned resources, and implemented to specifically address these priorities. Specific program activities are described and categorized by the four service levels within the MCH “pyramid” — direct health care, enabling, population-based, and infrastructure building services. Because of the flexibility inherent in the Block Grant, the program activities or the role that Title V plays in the implementation of each performance measure may vary among States (i.e., monitor, advocate, provide, supplement, assure). Program activities, as measured by 18 National Performance Measures and 7 to 10 State Performance Measures should have a collective contributory effect to positively impact a set of 6 National Outcome Measures for the Title V population.

Accountability is determined in 3 ways: (1) by measuring the progress towards successful achievement of each individual performance measure; (2) by having budgeted and expended dollars in all four of the recognized MCH services; direct health care, enabling services, population-based services, and infrastructure building services, and (3) by having a positive impact on the outcome measures.

While improvement in outcome measures is the long term goal, more immediate success may be realized by positive impact on the performance measures which are shorter term, intermediate, and precursors for the outcome measures. This is particularly important because there may be other significant factors outside of Title V control affecting the outcome measures.

Shape9 Shape59

Figure 3

TITLE V BLOCK GRANT

PERFORMANCE MEASUREMENT SYSTEM

DIRECT

HEALTH

ENABLING

SERVICES

POPULATION

BASED

INFRASTRUCTURE

SERVICES

PROGRAM AND RESOURCE

ALLOCATION

PERFORMANCE

MEASURES

OUTCOME

MEASURES

PRENATAL

CARE

MEDICAL

HOME

NEWBORN

SCREENING

CHILDREN

WITH NO

INSURANCE

PRIORITIES

NEEDS ASSESSMENT

HEALTH STATUS/

HEALTH SYSTEMS

CAPACITY INDICATORS

LOWER INFANT

DEATH

DECREASE TEEN

PREGNANCY

INCREASE ACCESS

FOR CSHCN

ASTHMA

HOSPITAL

DISCHARGES

BIRTHS LESS

THAN 2500

GRAMS

ACCESS TO MCH

DATA SETS

MEDICAID

INFANT DEATH

RATES

PERINATAL

MORTALITY

INFANT

MORTALITY

NEONATAL

MORTALITY

POSTNEONATAL

MORTALITY

CHILD

MORTALITY

INFANT

DEATH

DISPARITY

B. State Priorities

Describe the relationship of the priority needs, the National and/or State Performance Measures, and the capacity and resource capability of the State Title V program. In this discussion, mention where appropriate, the specific number of the National and State Performance Measures that relate to those activities. Details of the development of performance measures and the relationships between priorities and performance measures are discussed in the following parts of this section, C and D.

C. National Performance Measures

Table 4a on the following page lists the 18 National Performance Measures. Each measure is described in the Detail Sheets beginning on page 95 and includes the following 5 major components — goal, definition, Healthy People 2020 objective, data sources/issues, and significance. A review of the Detail Sheets assists in assuring a consistent understanding and reporting of the measures among States and in the aggregation of National performance results.

In this section of the narrative discuss, in numerical order, each of the 18 National Performance Measures. The discussion should focus on MCH populations served and activities identified by service level of the pyramid. The discussion should be organized by: (a) a report of last year’s (annual report) accomplishments, (b) current activities, and (c) plan for the coming (application) year.

There may be multiple activities for each performance measure. Discuss activities as they relate to the population groups, etc., and discuss how each activity relates to the level of the pyramid. Major activities conducted during the annual report year should be listed on Table 4a. Specific activities may reflect different service levels of the pyramid than the corresponding performance measure. An example of some activities has been provided for the first Performance Measure in Table 4a. Each State should provide their listing of major activities for each corresponding performance measure. Up to ten major activities per each performance measure may be listed.

TABLE 4a

NATIONAL PERFORMANCE MEASURES SUMMARY FROM THE ANNUAL REPORT YEAR

DHC ES PBS IB NATIONAL PERFORMANCE MEASURES	Pyramid Level of Service
DHC ES PBS IB NATIONAL PERFORMANCE MEASURES		ES	PBS	IB
1 X XXX ) The percent of screen positive newborns who received timely follow up to definitive diagnosis and clinical management for condition(s) mandated by their State-sponsored newborn screening programs. List all major ongoing activities, such as: 1. Purchase of PKU formula and food products for individuals* 2. Contracts providing statewide coverage for consultation related with related metabolic conditions. 3. Development of a data system linking newborn screening records with birth certificates. 4. Arranging transportation, as needed, to access follow up services.	x	x	X x	x
2 X ) The percent of children with special health care needs age 0 to 18 whose families partner in decision-making at all levels and are satisfied with the services they receive. (CSHCN Survey) *List all ongoing major activities. 1. 2. 3. 4.				X
3 X ) The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing, comprehensive care within a medical home. (CSHCN Survey) *List all ongoing major activities. 1. 2. 3. 4.		X
4 X ) The percent of children with special health care needs age 0 to 18 whose families have adequate private and/or public insurance to pay for the services they need. (CSHCN Survey) *List all ongoing major activities. 1. 2. 3. 4.				X
5 X ) The percent of children with special health care needs age 0 to 18 whose families report the community-based service system are organized so they can use them easily. (CSHCN Survey) *List all ongoing major activities. 1. 2. 3. 4.		X
6 X ) The percentage of youth with special health care needs who received the services necessary to make transitions to all aspects of adult life, including adult health care, work, and independence. (CSHCN Survey) *List all major ongoing activities. 1. 2. 3. 4.	X
7 X ) Percent of 19 to 35 month olds who have received full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilus Influenza, Hepatitis B. *List all major ongoing activities. 1. 2. 3. 4.			X
8 X ) The rate of birth (per 1,000) for teenagers aged 15 through 17 years. *List all major ongoing activities. 1. 2. 3. 4.			X
9 X ) Percent of third grade children who have received protective sealants on at least one permanent molar tooth. *List all major ongoing activities. 1. 2. 3. 4.			X
1 X 0) The rate of deaths to children aged 14 years and younger caused by motor vehicle crashes per 100,000 children. *List all major ongoing activities. 1. 2. 3. 4.			X
1 X 1) The percent of mothers who breastfeed their infants at 6 months of age. *List all major ongoing activities. 1. 2. 3. 4.			X	X
1 X 2) Percentage of newborns who have been screened for hearing before hospital discharge. *List all major ongoing activities. 1. 2. 3. 4.			X
1 X 3) Percent of children without health insurance. *List all major ongoing activities. 1. 2. 3. 4.				X
1 X 4) Percentage of children, ages 2 to 5 years, receiving WIC services that have a Body Mass Index (BMI) at or above the 85th percentile. *List all major ongoing activities. 1. 2. 3. 3.				X
1 X 5) Percentage of women who smoke in the last three months of pregnancy *List all major ongoing activities. 1. 2. 3. 4.				X
1 X 6) The rate (per 100,000) of suicide deaths among youths 15-19. *List all major ongoing activities. 1. 2. 3. 4.				X
1 X 7) Percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates. *List all major ongoing activities. 1. 2. 3. 4.				X
1 X 8) Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester. *List all major ongoing activities. 1. 2. 3. 4.				X

NOTE: DHC = Direct Health Care ES = Enabling Services PBS = Population Based Services IB = Infrastructure Building. *List all major ongoing activities in the space provided. More than four major on-going activities may be included, please include no more than ten.

TABLE 4b

STATE PERFORMANCE MEASURES SUMMARY FROM THE ANNUAL REPORT YEAR

S DHC ES PBS IB TATE PERFORMANCE MEASURES	Pyramid Level of Service
S DHC ES PBS IB TATE PERFORMANCE MEASURES	DHC	ES	PBS	IB
1). *List all major ongoing activities for each measure and mark a corresponding level of service.
2.)
3.)
4.)
5.)
6.)
7.)
8.)
9.)
10).

NOTE: DHC=Direct Health Care ES=Enabling Services PBS=Population Based Services IB=Infrastructure Building. *List all major ongoing activities in the space provided for each State Performance Measure.

D. State Performance Measures

In order to promote State flexibility, while assuring accountability in responding to the specific priority needs determined through the Needs Assessment, each State shall develop at least 7, but not more than 10, additional performance measures based on their identified priorities that best describe their own unique needs and may be similar to, but not otherwise captured by, the National Performance Measures. For each State Performance Measure (SPM), complete a Performance Outcome Measure Detail Sheet (Form 16).

In this section of the narrative, if there have been changes to any of the SPMs since the last application, discuss each new SPM in terms of why it was chosen, and its relationship to one or more of the priority needs.

For all SPMs, the discussion should include MCH populations served and activities identified by service level of the pyramid. The discussion should be organized by: (a) a report of last year’s (annual report) accomplishments, (b) current activities, and (c) plan for the upcoming (application) year. It is understood that there may be more than one activity for each performance level. These activities may relate to different levels of the pyramid and more than one MCH population.

Lastly, in order to provide a performance measurement summary, list all major activities that occurred during the annual report year under each performance measure in Table 4b, page 42. There are ten lines provided to list four to ten major activities for up to ten State Performance Measures.

SPMs are reviewed relative to the priorities established in the Needs Assessment; their representation of important State Title V program activities; and to ensure that they are generally measurable and relevant. The review process also provides an opportunity to increase consistency among similar measures submitted by other States by encouraging uniform definitions of numerators and denominators that may lead to National data aggregation of corresponding measures.

Since it is likely that priority needs and program activities change and evolve over time, the SPMs may need to be discontinued when new ones are added. In any given year, when a State measure is discontinued, reporting on that measure is no longer required and a State may ‘deactivate’ the measure in the system. In this case, the State should provide an explanation of the reason for deactivating the measure. In the first interim reporting year after a Needs Assessment year any State measures that were dropped at any time in the previous 5 year reporting cycle are removed from Table 4b and Forms 11, 12, and 16 (Detail Sheets).

E. Health Status Indicators

The Health Status Indicators (HSIs) inform States’ future programming of public health efforts. The indicators serve as a surveillance monitoring tool and provide information on the State’s health outcomes. States should thoughtfully examine their indicators on an ongoing basis and look for trends across the MCH health system.

The indicator data for all twelve HSIs are documented annually on Forms 20 and 21.

The State Title V agency may choose one, some, or all of the most relevant indicators to discuss in the narrative section. Within the 12 HSI narrative sections describe those indicators that best inform the State’s future program planning efforts. If applicable, describe the data source(s). In the HSI narrative section, States may also choose to describe such items as:

What do the Health Status Indicators show? (trend analysis)
Which trends or indicators are most critical or sentinel to your work? (prioritizing)
For relevant indicators, what is your desired outcome? (evaluation)
Based on the trend analysis/prioritized indicators what programming or policy changes are needed for the desired impact? (quality improvement)

SUMMARY OF HEALTH STATUS INDICATORS

Reported Annually

#01A. The percent of live births weighing less than 2,500 grams.

#01B. The percent of live singleton births weighing less than 2,500 grams.

#02A. The percent of live births weighing less than 1,500 grams.

#02B. The percent of live singleton births weighing less than 1,500 grams.

#03A. The death rate per 100,000 due to unintentional injuries among children aged 14 years and younger.

#03B. The death rate per 100,000 from unintentional injuries due to motor vehicle crashes among children aged 14 years and younger.

#03C. The death rate per 100,000 from unintentional injuries due to motor vehicle crashes among youth aged 15 through 24 years.

#04A. The rate per 100, 000 of all nonfatal injuries among children aged 14 years and younger.

#04B. The rate per 100,000 of nonfatal injuries due to motor vehicle crashes among children aged 14 years and younger.

#04C. The rate per 100,000 of nonfatal injuries due to motor vehicle crashes among youth aged 15 through 24 years.

#05A. The rate per 1,000 women aged 15 through 19 years with a reported case of chlamydia.

#05B. The rate per 1,000 women aged 20 through 44 years with a reported case of chlamydia.

#06A & B. Infants and children aged 0 through 24 years enumerated by sub-populations of age group, race, and ethnicity.

#07A & B. Live births to women (of all ages) enumerated by maternal age, race and ethnicity.

#08A & B. Deaths to infants and children aged 0 through 24 years enumerated by age subgroup, race and ethnicity.

#09A & B. Infants and children aged 0 through 19 years in miscellaneous situations or enrolled in various State programs enumerated by race and ethnicity

#10. Geographic living area for all resident children aged 0 through 19 years

#11. Percent of the State population at various levels of the federal poverty level

#12. Percent of the State population aged 0 through 19 years at various levels of the federal poverty level

F. Other Program Activities

State MCH program activities have considerable breadth. In order to adequately describe those activities which fall outside the parameters of priority needs and National and State Performance Measures outlined above, separate descriptions may be necessary. Any activity not discussed within the priority needs and the performance measurement sections should be described here. These program activities often make significant contributions to the health and well-being of mothers and infants, children, and CSHCN within each State. Without these on-going program activities, the MCH population groups would not benefit from the full array of services available to them in some States. Each State has the opportunity to present these other activities in this section of the Application/Annual Report. Examples of other important issues for discussion here may include the following: (1) characteristics documenting family/consumer participation in MCH and CSHCN programs; (2) special efforts made to address health disparities; (3) evaluations that have been recently completed, are ongoing, or are planned relative to State MCH and CSHCN activities; (4) cultural competency; or (5) any other specific changes or challenges in the upcoming year not covered elsewhere in the application.

Include a discussion of the toll-free hotline [Section 505(a)(5)(E)].

G. Technical Assistance Needs

Form 15 is to obtain a preliminary idea of the programmatic areas in which the State would like technical assistance, consultation, or capacity building activities. The items listed on this form will be regarded as a starting point for the State and for MCHB to plan an efficient and effective strategy for obtaining the most appropriate technical assistance (TA) to meet the State's unique needs. Priority will be given to providing technical assistance in those areas where the State desires to increase its progress in realizing one or more of its State or National Performance Measures. In some cases, the State may want to obtain technical assistance from another State who has achieved a high level of performance (peer-to-peer exchange). States may also be interested in obtaining TA from other experts at universities, public health agencies, consulting firms, etc. or holding a regional workshop. The State may clarify its TA needs over the course of the year. To receive technical assistance, the State must complete and submit a TA Request Form which can be obtained by contacting the assigned MCHB Project Officer.

V - BUDGET NARRATIVE

Expenditures

The State should maintain budget documentation for Block Grant funding/expenditures for reporting, consistent with Section 505(a), and consistent with Section 506(a)(1) for audit. Describe any significant year to year expenditure variations that appear on Forms 3, 4, or 5.

Budget

The budget narrative is to reflect how Federal support complements the State’s total effort and what amounts will be spent in compliance with the 30% - 30% requirements. It should further describe how other spending categories (administration and maintenance of effort) of Title V funds as shown on Form 2 are maintained. Describe how satisfaction of the required match is achieved. Adequate discussion is included for significant year to year variations in budget or expenditures.

In this section describe briefly the maintenance of effort from 1989 [Sec. 505(a)(4)]; any continuation funding for special projects [Sec. 505(a)(5)(C)(i)]; or special consolidated projects noted in Sec. 501(b)(1) [Sec. 505(a)(5)(B)].

The budget justification should further describe sources of other Federal MCH dollars, State matching funds, including non-federal dollars that meet at least the legislatively-required minimum match for Title V, and other State funds used by the agency to provide the Title V program. Describe any significant year to year budget variations that appear on Forms 3, 4, or 5.

Remember that any amount payable to a State under this title from allotments for a fiscal year which remains unobligated at the end of such year shall remain available to such State for obligation during the next fiscal year. No payment may be made to a State under this title from allotments for a fiscal year for expenditures made after the following fiscal year [Section 503(b)].

VI - REPORTING FORMS - GENERAL INFORMATION

Application for Federal Assistance - This is the “official” application form requiring electronic signature by the appropriate State official.

The Application Face Sheet (SF424) is a standard Office of Management and Budget (OMB) form that is completed electronically in EHB. The form should be filled out in accordance with the standard instructions that accompany it. However, in order to have it serve MCHB purposes some definitions in its sub-sections have been assigned new meanings. These are spelled out in the detailed instructions that follow the form.

Form 2 - MCH Budget Details for FY__. – This is the annual planning form. It presents, at a glance all the funding by the Federal - State Block Grant Partnership and other MCH related funding sources. It also stipulates what amounts will be spent in compliance with the various spending requirements such as the 30%-30% requirements, administration and maintenance of effort (see page 13 for spending requirements detail).

Form 2 is also the “drive” form for the budget figures that appear on financial Forms 3, 4, and 5. The figures entered for the application year will automatically be entered in the appropriate “budgeted” columns in those forms. Care should be taken to complete this form accurately.

Form 3 - State MCH Funding Profile - This form is used for both reporting and planning purposes. For Annual Report purposes complete the “Expended” column for the appropriate Fiscal Year.

Form 4 - Budget Details by Types of Individuals Served (I) and Sources of Other Federal Funds (II) - This form is used for both reporting and planning purposes. For Annual Report purposes complete the “Expended” column for the appropriate Fiscal Year. For Annual Plan purposes complete the “Budgeted” column for the appropriate Fiscal Year.

Form 5 - State Title V Program Budget and Expenditures by Types of Service - Form 5, “State Title V Programs Budget and Expenditures by Types of Service” parallels the pyramid shown in Figure 1, page 5, which organizes Maternal and Child Health Services from direct health care services through infrastructure building. Because the narrative description and the implementation of performance measures are integrally related to this pyramid, special care should be used in completing the appropriate fiscal year Expended fund column on this form.

Form 6 - Number and Percentage of Newborn and Others Screened, Cases Confirmed, and Treated - Annual Report form.

Form 7 - Number of Individuals Served Under Title V - Annual Report form.

Form 8 - Deliveries and Infants Served by Title V and Entitled to Benefits Under Title XIX - Annual Report form.

Form 9 - State MCH Toll-Free Telephone Line Data - Part of the Annual Report.

Form 10 - Title V Maternal & Child Health Services Block Grant State Profile for FY__. - The information in this profile will be used for the TVIS Snapshot pages to quickly summarize a State’s accomplishments during the last fiscal year. Follow the instructions carefully. The TVIS Snapshot pages are located at:

https://perfdata.hrsa.gov/MCHB/TVISReports/Snapshot/SnapShotMenu.aspx

Form 11 - Tracking Performance Measures – This form lists the 18 National Performance Measures and up to 10 State Performance Measures and the objectives (targets) and the indicators (actual progress) for each, by fiscal year.

For National Performance Measures: For Annual Report purposes complete the appropriate fiscal year annual performance indicators by entering data into the “Numerator” and “Denominator” rows for each of the National and State Performance Measures. Using this data, the indicator will be automatically calculated and entered in the appropriate row for the measure. For Annual Plan purposes complete the annual performance objective row for the State’s five year targets for each measure.

For the State Performance Measures: Complete Form 11 by adding each State Performance Measure after the National measures.

For both National and State Performance Measures: Since it is likely that priority needs and program activities will evolve over time it is also likely the performance objective values may need to be changed. These values may be changed in either the National or State measures if necessary. When changed, add a note using the notes feature in the Title V Information System on Form 11 explaining the reasons for the change. State measures can be retired in the Title V Information System by selecting “inactive” from the detail sheet data entry page. Please refer to the instructions on Form 11 – SPMs within TVIS for more details.

Form 12 - Tracking Health Outcome Measures – This lists the 6 National Outcome Measures and, if developed, optional State Outcome Measure and the objectives (targets) and the indicators (actual progress) for each, by year.

For the State Measure: Complete Form 12 by adding the State’s (optional) Outcome Measure after the National measures.

For Annual Report purposes: Complete the appropriate fiscal year annual outcome indicators by entering data into the “Numerator” and “Denominator” rows for each of the National and State Outcome Measure. Using this data, the indicator will be automatically calculated and entered in the appropriate row for the measure.

For Annual Plan purposes: Complete the annual outcome objective row for the State’s five year objectives for each measure.

Form 13 – Characteristics Documenting Family Participation in Children With Special Health Care Needs - This form will provide an idea of the characteristics documenting family participation in the care of children with potential or actual chronic and disabling conditions and their families. Please contact your designated MCH Block Grant federal project officer if you are interested in receiving information on resources available to assist in the completion of Form 13.

Form 14 - List of MCH Priority Needs - This form will provide a summary of the 5-Year Statewide Needs Assessment. Use information about the health status of the MCH population gathered as a result of the 5-Year Statewide Needs Assessment. Condense this data into a summary of the State's top 7 to 10 needs and place them on this form. Use a simple phrase, such as: "The infant mortality rate for minorities should be reduced," or, "To reduce the barriers to the delivery of care for pregnant women.” Each of the three population groups should be covered by the State’s selected priorities. The Title V Information System will record up to 10 priority needs, but the State may list and describe more if desired in a form note.

Form 15 - Technical Assistance (TA) Planning Form - A preliminary listing of the State’s technical assistance needs for the next fiscal year. This form’s purpose is to assist States in identifying major issues in the coming year and to begin preliminary planning in determining their ongoing TA needs. Furthermore, this form will develop discussion areas for Title V MCH Services Block Grant to States Program Application/Annual Report reviewers and assist MCHB staff in strategizing the most appropriate technical assistance to meet the State’s unique needs. To receive technical assistance, the State must complete and submit a TA Request Form which can be obtained by contacting the assigned MCHB project officer.

Form 16 - State Performance/Outcome Measure Detail Sheet – This contains the details of all the data elements that make up the State Performance and Outcome Measures. These data elements are: title, service level category (direct health services, enabling services, population-based services, or capacity/infrastructure), goal, measure, definition, Healthy People 2020 objective, data source and data issues, and a description of the measure’s significance.

For State Performance Measures: These Detail Sheet forms are identical in format to the National Performance Measure Detail Sheets. They should be completed in that format and with terminology similar to that found in the National Performance Measure Detail Sheets. For these State Performance Measure Detail Sheets it is important to include as much detail as can be determined for all of the data elements. When a Form 16 Detail Sheet is completed for each of the State Performance Measures, the title of that measure will be automatically added to Table 4b, and Form 11. It is recognized that the assignment of service level (of the MCH pyramid) is a matter of judgment and should be chosen by the primary category of program activities planned to meet the measure during the next 5 years.

For the State Outcome Measure: Each State may also develop one additional State Outcome Measure. Use Form 16 to enumerate the details of the measure in the same manner as described for the State Performance Measures above.

For both National and State measures: Footnotes containing additional explanatory material may be added to the Detail Sheets to enhance understanding or highlight special conditions or concerns within the State. This is important since all of the National Performance and Outcome Measures have been and will continue to be, a "work in progress" and, taken together, the conditions and concerns represent various developmental stages from the recommendations on data collection methods, to the collection of baseline information that may lead to the development of more sophisticated performance measurements.

Form 17 – Health System Capacity Indicators – Reporting/Tracking Forms for HSCIs 01, 02, 03, 04, 07 & 08

Form 18 – Health Systems Capacity Indicators –Reporting/Tracking Forms for HSCIs 05 and 06

Form 19 – Health Systems Capacity Indicators – Reporting/Tracking Forms for HSCIs 09A and B

Form 20 – Health Status Indicators #01 - #05

Form 21—Health Status Indicators #06 - #12

FORMS

APPLICATION FOR

FEDERAL ASSISTANCE OMB Approval No. 0348-0043

						DATE SUBMITTED			Applicant Identifier
TYPE OF SUBMISSION: Application  Construction  Non-Construction		Pre-application  Construction  Non-Construction				3. DATE RECEIVED BY STATE			State Application Identifier
						4. DATE RECEIVED BY FEDERAL AGENCY			FEDERAL IDENTIFIER
5. APPLICANT INFORMATION
Legal Name:							Organizational Unit:
Address (give city, county, state, and zip code)							Name and telephone number of the person to be contacted on matters involving this application (give area code)
E MPLOYER IDENTIFICATION NUMBER (EIN): ─							7. TYPE OF APPLICANT: (Enter appropriate letter in box) A. State H. Independent School District B. County I. State Controlled Institution of Higher Learning C. Municipal J. Private University D. Township K. Indian Tribe E. Interstate L. Individual F. Intermunicipal M. Profit Organization G. Special District N. Other (Specify)________________________
8. TYPE OF APPLICATION:  New  Continuation  Revision If Revision, enter appropriate letter(s) in box (es)   A. Increase Award B. Decrease Award C. Increase Duration Decrease Duration Other (specify): ________________________________________________							9. NAME OF FEDERAL AGENCY:
C ATALOG OF FEDERAL DOMESTIC _ ASSISTANCE NUMBER: TITLE:							DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:
AREAS AFFECTED BY PROJECT (cities, counties, states, etc.)
13. PROPOSED PROJECT:			14. CONGRESSIONAL DISTRICTS OF:
Start Date	Ending Date		a. Applicant					b. Project

15. ESTIMATED FUNDING:				16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a. YES, THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12373 PROCESS FOR REVIEW ON DATE _______________________________________________ b. NO  PROGRAM IS NOT COVERED BY E.O. 12372  OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW
a. Federal	$ .00
b. Applicant	$ .00
c. State	$ .00
d. Local	$ .00
e. Other	$ .00
f. Program Income	$ .00			IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT  Yes If “Yes”, attach an explanation  No
g. TOTAL	$ .00
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. Typed Name of Authorized Representative					b. Title					Telephone number
d. Signature of Authorized Representative										Date Signed

Previous Editions Not Usable Standard Form 424 (REV. 4-88)

Prescribed by OMB A-102

INSTRUCTIONS FOR THE SF 424

This is a standard form used by applicants as a required face sheet for the pre-applications and applications submitted for Federal Assistance. It will be used by Federal agencies to obtain applicant certification that States which have established a review and government procedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given an opportunity to review the applicant’s submission.

			Item:				Entry:			Item:				Entry:
		1.				Self-explanatory			12.				List only the largest political entities affected (e.g., State, counties
2.				Date application				13.			Self-explanatory
		3.				State use only (if applicable).			14.				List the applicant’s Congressional District and Districts affected by the program or project.
		4. 5.				If this application is to continue or revise an existing award, enter present Federal identifier number. If for a new project, leave blank. Legal of applicant, name of primary organizational unit which will undertake the assistance activity, complete address of the applicant, and name and telephone number of the person to contract on matters related to this application.			15.				Amount requested or to be contributed during the first funding/budget period by each contributor. Value of in-kind contributions should be included on appropriate lines as applicable. If the action will result in a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parenthesis. If both basic and supplemental amounts are included, show breakdown on an attached sheet. For multiple program funding, use totals and show breakdown using same categories as in Item 15.
		6. 7.				Enter Employer Identification Number (EIN) as assigned by the Internal Revenue Service. Enter the appropriate letter in the space provided.			16.				Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process.
		8.				Check the appropriate box and enter appropriate letter(s) in the space(s) provided: “New” means a new assistance award “Continuation” means an extension for an additional funding/budget period for a project with a projected completion date. “Revision” means any change in the Federal Government’s financial obligation or contingent liability from an existing obligation.			17.				This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of debt include delinquent audit disallowances, loans and taxes.
		9.				Name of Federal agency from which assistance is being requested with this application.			18.				To be signed by the authorized representative of the applicant. A copy of the governing body’s authorization for you to sign this application as official representative must be on file in the applicant’s office. (Certain Federal agencies may require that this authorization be submitted as part of the application.)
		10.				Use the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested.
	11.				Enter a brief descriptive title of the project, if more than one program is involved, you should append an explanation on a separate sheet. If appropriate (e.g., construction or real property projects), attach a map showing project location. For pre-applications, use a separate sheet to provide a summary description of this project.							SF 424 (REV 4-88) Back

INSTRUCTIONS FOR THE COMPLETION OF

APPLICATION FACE SHEET (standard form 424)

The Application Face Sheet (SF424) is not subject to revision; it is an OMB standard form that can be revised by OMB only. The Form should be filled out in accordance with the standard instructions that accompany it. However, in order for the SF424 to serve MCHB purposes, the sub-groupings of funding categories under Section 15 will be defined as follows:

Estimated Funding:

a. Federal - The Title V MCH Block grant allocation only.

b. Applicant - The unobligated balance from previous year’s MCH Block Grant allocation.

c. State - Total State funds. The State’s total matching funds plus overmatch for the Title V Allocation.

d. Local - Total of MCH dedicated funds from local jurisdictions within the State.

e. Other - Foundation and other public and private and non-profit monies, used for Title V programs.

f. Program Income - Funds collected by State MCH agencies from insurance payments, Medicaid, HMOs, etc.

g. TOTAL - ALL the MCH funds administered by the State MCH program.

FORM 2

MCH BUDGET DETAILS FOR FY ____

[Secs.504(d) and 505(a)(3)(4)]

1. FEDERAL ALLOCATION $__________

(Item 15a of the Application Face Sheet [SF 424]

Of the Federal Allocation (1 above), the amount earmarked for:

A. Preventive and primary care for children:

$________________ (_____%)

B. Children with special health care needs:

$________________ (_____%)

(If either A or B is less than 30%, a waiver request must

accompany the application) [Sec. 505(a)(3)]

C. Title V administrative costs:

$_________________(_____%)

(The above figure cannot be more than 10% [Sec. 504(d)]

2. UNOBLIGATED BALANCE (Item 15b of SF 424) $__________

3. STATE MCH FUNDS

(Item 15c of SF 424) $__________

4. LOCAL MCH FUNDS (Item 15d of SF424) $__________

5. OTHER FUNDS (Item 15e of the SF 424) $__________

6. PROGRAM INCOME (Item 15f of SF 424) $__________

7. TOTAL STATE MATCH (Lines 3 through 6)

(Enter below your State=s FY1989 Maintenance of Effort Amount) $_____________

$______________________

8. FEDERAL-STATE TITLE V BLOCK GRANT PARTNERSHIP (SUBTOTAL) $____________ (Total lines 1 through 6. Same as line 15g of SF 424)

9. OTHER FEDERAL FUNDS

(Funds under the control of the person responsible for the

administration of the Title V program)

a. SPRANS: $________

b. SSDI: $________

c. CISS: $________

d. Abstinence Education $________

e. Healthy Start: $________

f. EMSC: $________

g. WIC: $________

h. AIDS: $________

i. CDC: $________

j. Education: $________

k. Home Visiting: $________

l. Other $________

$________

10. OTHER FEDERAL FUNDS (SUBTOTAL of all funds under item 9) $__________

11. STATE MCH BUDGET GRAND TOTAL $__________

(Partnership subtotal + Other Federal MCH Funds subtotal)

INSTRUCTIONS FOR COMPLETION OF FORM 2

MCH BUDGET DETAILS FOR FY ____

Title V Citation: Section 504(d) states: “Of the amounts paid to a State...not more than 10 percent may be used for administering the fund paid...@ In order to be entitled to payments for allotments under Title V, Section 505(a)(3) provides that the State will use: “(A) at least 30 percent of such payment amounts for preventive and primary care services for children, and (B) at least 30 percent of such payment amounts for services to children with special health care needs.@ Section 505(a)(4) provides that “a State receiving funds for maternal and child health services...shall maintain the level of funds being provided solely by such State for maternal and child health programs at a level at least equal to the level that such State provided for such programs in fiscal year 1989...@

Instructions: A glossary of terms is presented in Part Two, Section VIII of this document.

This form provides details of the State=s MCH budget and the fulfillment of certain spending requirements under Title V for a given year.

Line 1. Enter the amount of the Federal Title V allocation. This is to be the same figure that appears in line 15a of the AFS (SF 424) and in the “Budgeted” column of line 1 of Form 3 (for the appropriate year).

Line 1A. Enter the amount of the Federal allotment your State is budgeting for preventive and primary care for children and enter the percentage of the total (Line 1) this amount represents.

Line 1B. Enter the amount of the Federal allotment your State is budgeting for children with special health care needs and enter the percentage of the total (Line 1) this amount represents.

Line 1C. Enter the amount of the Federal allotment your State is budgeting for the administration of the allotment and enter the percentage of the total (Line 1) this amount represents.

Line 2. Enter the amount of carryover from the previous year=s MCH Block Grant Allocation (the unobligated balance). This is to be the same figure that appears in line 15b of the AFS (SF 424) and in the “Budgeted“ column of line 2 of Form 3 (for the appropriate year).

Line 3. Enter the amount of your State total funds for the Title V allocation (match). This is to be the same figure that appears in line 15c of the AFS (SF 424) and in the “Budgeted” column of line 3 of Form 3 (for the appropriate year).

Line 4. Enter the amount of total MCH dedicated funds garnered from local jurisdictions within your State. This is to be the same figure that appears in line 15d of the AFS (SF 424) and in the “Budgeted” column of line 4 of Form 3 (for the appropriate year).

Line 5. Enter the total of MCH funds available from other sources such as foundations. This is to be the same figure that appears in line 15e of the AFS (SF 424) and in the “Budgeted” column of line 5 of Form 3 (for the appropriate year).

Line 6. Enter the amount of MCH program income funds collected by your State=s MCH agencies from insurance payments, MEDICAID, HMO=s, etc. This is to be the same figure that appears in line 15f of the AFS (SF 424) and in the “Budgeted” column of line 6 of Form 3 (for the appropriate year).

Line 7. Enter the sum total of Lines 3, 4, 5, and 6 for the total of your State match and overmatch.

Line 7A. Enter your State=s FY 1989 Maintenance of Effort amount.

Line 8. Enter the amount of the total of lines 1, 2, and 7. This is the “Federal-State Title V Block Grant “Partnership” and is to be the same figure that appears in line 15g of SF 424 and in the “Budgeted” column of line 7 of Form 3.

Line 9. On the appropriate lines (a through k) enter Federal funds other than the Title V Block Grant that are under the control of the person responsible for the administration of the Title V program. If line 8k is utilized, specify the source(s) of the funds in the order of the amount provided starting with the source of the most funds. If more than two lines are required, add a footnote at the bottom of the page showing additional sources and amounts.

Line 10. Enter the sum of all Lines in item 9. This is to be the same figure that appears in the “Budgeted” column of line 8 of Form 3 (for the appropriate year).

Line 11. Enter the sum of lines 7 and 10. This is the total of all MCH funds administered by your State=s MCH program and is to be the same figure that appears in the “Budgeted” column of line 9 of Form 3 (for the appropriate year)

FORM 3

STATE MCH FUNDING PROFILE

[Secs. 505(a) and 506((a)(I-3)]

FY 2007 FY 2008 FY 2009 FY 2010 FY 2011

Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended

1. Federal

Allocation

(Line 1, Form 2)

$________

$_________

$________

$_________

$________

$_________

$________

$__________

2. Unobligated

Balance

(Line 2, Form 2)

$__________

3. State

Funds

(Line 3, Form 2)

$__________

4. Local MCH

Funds

(Line 4, Form 2)

$__________

5. Other Funds

(Line 5, Form 2)

$__________

6. Program

Income

(Line 6, Form 2)

$__________

7. SUBTOTAL

(Line 8, Form 2)

$__________

(THE FEDERAL-STATE TITLE BLOCK GRANT PARTNERSHIP)

8. Other

Federal

Funds

(Line 10, Form 2

$__________

9. TOTAL

(Line 11, Form 2)

$__________

(STATE MCH BUDGET TOTAL)

FORM 3

STATE MCH FUNDING PROFILE

[Secs. 505(a) and 506((a)(I-3)]

FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended

1. Federal

Allocation

(Line 1, Form 2)

$__________

2. Unobligated

Balance

(Line 2, Form 2)

$__________

3. State

Funds

(Line 3, Form 2)

$__________

4. Local MCH

Funds

(Line 4, Form 2)

$__________

5. Other Funds

(Line 5, Form 2)

$__________

6. Program

Income

(Line 6, Form 2)

$__________

7. SUBTOTAL

(Line 8, Form 2)

$__________

(THE FEDERAL-STATE TITLE BLOCK GRANT PARTNERSHIP)

8. Other

Federal

Funds

(Line 10, Form 2

$__________

9. TOTAL

(Line 11, Form 2)

$__________

(STATE MCH BUDGET TOTAL)

INSTRUCTIONS FOR THE COMPLETION OF FORM 3

STATE MCH FUNDING PROFILE

Title V Citation: Section 505(a) states, in part: “In order to be entitled to payments for allotments...a State must prepare and transmit to the Secretary an application (in a standard form specified by the Secretary)...” The columns labeled “Budgeted” on this form are intended to partially fulfill the Secretary’s application requirements.

Section 506(a)(1-3) describes the annual reporting requirements that, “each State shall prepare and submit to the Secretary annual reports on its activities under this title.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote.

The form is intended to provide “at a glance” funding data on the estimated budgeted amounts and actual expended amounts of a State’s MCH program. For each fiscal year, the lines under the columns labeled “Budgeted” are to contain the same figures (for that year) that appear in section 15 of Application Face Sheet (SF 424) for that year. Lines 1 through 7 are also to contain the same figures (for the applicable year) as lines 1 through 6 and 8 of Form 2, and Line 8 is to contain the same figure as Line 10 of Form 2, and Line 9 is to contain the same figure as Line 11 of Form 2. The lines under the columns labeled “Expended” are to contain the actual amounts expended for the applicable year.

FORM 4

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (1) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

[Secs 506(2)(2)(iv)

FY 2009 FY 2010

I. Federal-State MCH

Block Grant Partnership

a. Pregnant Women

Budgeted

$__________

Expended

$________

Budgeted

$__________

Expended

$________

b. Infants < 1 year old

$__________

$________

$__________

$________

c. Children 1 to 22 years old

$__________

$________

$__________

$________

d. CSHCN

$__________

$________

$__________

$________

e. All Others

$__________

$________

$__________

$________

f. Administration

$__________

$________

$__________

$________

g. SUBTOTAL

$__________

(Line 8 and Line 7, Form 3)

$________

(Line 7, Form 3)

$__________

(Line 8 and Line 7, Form 3)

$________

(Line 7, Form 3)

II. Other Federal Funds (under the control of the person responsible for administration of the Title V program).
a. SPRANS	$__________	$__________
b. SSDI	$__________	$__________
c. CISS	$__________	$__________
d. Abstinence Education	$__________	$__________
e. Healthy Start	$__________	$__________
f. EMSC	$__________	$__________
g. WIC	$__________	$__________
h. AIDS	$__________	$__________
i. CDC	$__________	$__________
j. Education	$__________	$__________
k. Home Visiting l. Other: ____________ (Specify)	$__________	$ _________
____________ (Specify)	$__________	$__________
____________ (Specify)	$__________	$__________
_____________ (Specify)	$__________	$__________
III. SUBTOTAL	$__________	$__________
	(Line 10, Form 2 and Line 8, Form 3)	(Line 10, Form 2 and Line 8, Form 3

FORM 4 (Continuation Page)

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (1) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

[Secs 506(2)(2)(iv)

FY 2011 FY 2012 FY 2013

Budgeted

Expended

Budgeted

Expended

Budgeted

Expended

$________

(Line 7 & Line 8, Form 3) (Line 7, Form 3)

(Line 7 & Line 8, Form 3) (Line 7, Form 3) (Line 7 & Line 8, Form 3) (Line 7, Form 3)

$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
$________	$________		$________
(Line 10, Form 2 and Line8, Form 3)		(Line 9, Form 2 and Line 8, Form 3)		Line 10, Form 2 and Line 8, Form 3)

FORM 4 (Continuation Page)

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (1) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

[Secs 506(2)(2)(iv)

FY 2014 FY 2015 FY 2016

Budgeted

Expended

Budgeted

Expended

Budgeted

Expended

$________

(Line 8 and Line 7, Form 3) (Line 7, Form 3)

(Line 8 and Line 7, Form 3) (Line 7, Form 3) (Line 8 and Line 7, Form 3) (Line 7, Form 3)

$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
$________	$________	$________
(Line 10, Form 2	(Line 9, Form 2	(Line 10, Form 2
and	and	and
Line8, Form 3)	Line 8, Form 3)	Line 8, Form 3)

INSTRUCTIONS FOR COMPLETION OF FORM 4

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (I) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

Title V Citation: Section 506(a)(2)(iv) requires that each State submit an annual report of its activities under its Title V program. Among the items required to be reported are, “...the amount spent under this title...by class of individuals served.”

Instructions: A glossary of terms applicable to the terms used in this form is provided in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates in a footnote.

Lines I(a) through I(f) - enter the budgeted and expended amounts for the appropriate fiscal year.

Line I(g) - enter the sum of the figures of lines I(a) through (f). Note that for the “Budgeted” columns this figure is to be the same figure that appears in the “Budgeted” column of Line 8, Form 2, and in Line 7, Form 3, and for the “Expended” column this is the same figure that appears in the “Expended” columns of Line 7, Form 3.

Lines II(a) through II(k) - enter the budgeted amounts for the appropriate fiscal year. Note that these figures are to be the same figures that appear in the “Budgeted” columns of lines 9(a) through (k) of Form 2.

Line III - enter the sum of the figures of lines II(a) through (k). Note that this figure is to be the same figure that appears in Line 10, Form 2, and in the “Budgeted” column of Line 8, Form 3.

FORM 5

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES

BY TYPES OF SERVICES

[Secs. 505(a)(2)(A-B) and 506(a)(1)(A-D)]

FY 2009 FY 2010

TYPES OF SERVICES Budgeted Expended Budgeted Expended

I. Direct Health Care Services $ $ $ $__________

(Basic Health Services and Health

Services for CSHCN.)

II. Enabling Services $ $ $ $__________

(Transportation, Translation,

Outreach, Respite Care, Health

Education, Family Support Services,

Purchase of Health Insurance,

Case Management, and Coordination

with Medicaid, WIC, and Education.)

III. Population-Based Services $ $ $ $__________

(Newborn Screening, Lead Screening,

Immunization, Sudden Infant Death

Syndrome Counseling, Oral Health,

Injury Prevention, Nutrition, and

Outreach/Public Education.)

IV. Infrastructure Building Services $ $ $ $___________

(Needs Assessment, Evaluation, Planning,

Policy Development, Coordination,

Quality Assurance, Standards Development,

Monitoring, Training, Applied Research,

Systems of Care, and Information Systems.)

V. FEDERAL-STATE TITLE V BLOCK

GRANT PARTNERSHIP

TOTAL $ $ $ $____________

(Federal-State Partnership only.

Item 15g of SF 424. For the “Budget”

columns this is the same figure that

appears in Line 8, Form 2, and in

the “Budgeted” columns of Line 7 Form 3.

For the “Expended” columns this is

the same figure that appears in the

“Expended” columns of Line 7, Form 3.)

FORM 5 (Continuation Page)

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES

BY TYPES OF SERVICES

[Secs. 505(a)(2)(A-B) and 506(a)(1)(A-D)]

FY 2011 FY 2012 FY 2013

Budgeted Expended Budgeted Expended Budgeted Expended

$ $ $ $ $ $___________

FORM 5 (Continuation Page)

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES

BY TYPES OF SERVICES

[Secs. 505(a)(2)(A-B) and 506(a)(1)(A-D)]

FY 2014 FY 2015 FY 2016

Budgeted Expended Budgeted Expended Budgeted Expended

$ $ $ $ $ $__________

INSTRUCTIONS FOR THE COMPLETION OF FORM 5

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES BY TYPES OF SERVICES

Title V Citation: Section 505(a)(2)(A)(B) and (B)(iii) states, in part, “In order to be entitled to payments for allotments...a State must prepare and transmit to the Secretary an application...that - includes for each fiscal year (A) a plan for meeting the needs identified by the state-wide needs assessment...and (B) a description of how funds allotted to the State...will be used for the provision and coordination of services to carry out such a plan that shall include - [(B)(iii)] an identification of the types of services to be provided...” Section 506(a)(1)(A-D) states, “Each State shall prepare and submit to the Secretary annual reports on its activities under this title. Each such report shall be prepared by, or in consultation with, the State maternal and child health agency. In order to properly evaluate and to compare the performance of different States assisted under this title and to assure the proper expenditure of funds under this title, such reports shall be in such standardized form and contain such information...as the Secretary determines...to be necessary (A) to secure an accurate description of those activities, (B) to secure a complete record of the purposes for which funds were spent, of the recipients of such funds, (C) to describe the extent to which the State has met the goals and objectives it set forth...and the national health objectives...and (D) to determine the extent to which funds were expended consistent with the State’s application...”

Instructions: A Glossary of terms applicable to the terms used in this form contained in Part Two, Section VIII of this document.

For reference see Figure 1, “Core Public Health Services Delivered by MCH Agencies.”

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote. Administrative dollars should be allocated to the appropriate level(s) of the pyramid on the lines below. If an estimate is necessary, one method would be to allocate those dollars at the same percentage as program dollars.

Line I. Direct Health Care Services - enter the budgeted and expended amounts for the appropriate fiscal year.

Line II. Enabling Services - enter the budgeted and expended amounts for the appropriate fiscal year.

Line III. Population-Based Services - enter the budgeted and expended amounts for the appropriate fiscal year.

Line IV. Infrastructure Building Services - enter the budgeted and expended amounts for the appropriate fiscal year.

Line V. Total Federal-State Partnership Budget and Expenditures - enter the totals of the budgeted and expended figures shown in lines I through IV for the appropriate fiscal year. Federal-State Partnership only; item 15g of the SF 424. For the “Budgeted” columns this is the same figure that appears in Line 8, Form 2, and in the “Budgeted” columns of Line 7, Form 3. For the “Expended” columns this is the same figure that appears in the “Expended” columns of Line 7, Form 3.

FORM 6

NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,

CASES CONFIRMED, AND TREATED

Sect. 506(a)(2)(B)(iii)

Total Births by Occurrence:_____________________ Reporting Year:

Type of Screening Tests

(A)

Receiving at

least one Screen(1)

No. %

(B)

No. Presumptive

Positive Screens

(C)

No. Confirmed

Cases(2)

(D)

Needing Treatment

that Received Treatment(3)

No. %

Phenylketonuria

(Classical)

Congenital Hypothyroidism

(Primary)

Galactosemia

(Classical)

Sickle Cell Disease

Other Screening (Specify)

Screening Programs for Older Children & Women (Specify Tests by name)

(1) Use occurrent births as denominator.

(2) Report only those from resident births.

(3) Use number of confirmed cases as denominator.

INSTRUCTIONS FOR THE COMPLETION OF FORM 6

NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,

CASES CONFIRMED, AND TREATED

Title V citation: Section 506(a)(2)(B)(iii) requires each State to submit an annual report on its activities under Title V. Included in this requirement is the following (iii) “... information on such other indicators of maternal, infant, and child health care status as the Secretary may specify.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote.

At the top of the form, on the lines “Total Births by Occurrence” and “Reporting Year” enter the total number of occurrent births for your State and the year for which the data applies. Total births by occurrence are to be defined as all births that occur in the State regardless of residency. Use the number submitted by vital records to the National Center for Health Statistics. The reporting year is to be defined as calendar year, Jan. 1 – Dec. 31. Please note that the “Total Births...” figure is related to the “Total infants < 1 year of age” row in Form 7, and the “TOTAL INFANTS IN STATE” row in section I of Form 8. While these figures are not expected to match, they should show a fairly close relationship to each other.

In column A, for all screening tests listed, enter the number and percentage of occurrent births that received one of the tests indicated. Percentage is to be based on occurrent births receiving one test out of the total listed at the top of the form.

In column B, enter the number of presumptive positive screens.

In column C, enter the number of confirmed cases discovered. Use only those from resident births.

In column D, enter the number and percent of those confirmed cases needing and receiving treatment. Use confirmed cases as the denominator.

Under “Other Screening” enter the specific names of any other screens not listed and then complete columns A through D. Other tests may include, but are not limited to: homocystinuria, biotinidase deficiency, and maple syrup urine disease.

Under “Screening Programs for Older Children and Women,” enter the specific names of any screening tests specific to those populations and then complete columns A through D. Note that the % (percentage) portion of column A is not to be completed since the denominator of Total Births by Occurrence does not apply.

All States now require screening for at least 2 disorders, and the four most common tests are specifically noted on the form, with room to write in other tests. All tests which are done during the reporting year should be listed along with the numbers screened and followed.

Follow-up is based on State activity; therefore, use resident live births for confirmed cases. For those needing treatment use confirmed cases as the denominator. If the program continues to monitor older children or adults for any of these conditions, these should be reported in the row labeled Screening Programs for Older Children and Women.

FORM 7

NUMBER OF INDIVIDUALS SERVED UNDER TITLE V

(By class of Individuals and Percent of Health Coverage)

[Sec. 506(a)(2)(A)(i-ii)]

Reporting Year__________
	(A)	(B)	(C)	(D)	(E)	(F)
	TITLE V	PRIMARY SOURCE OF COVERAGE
		Title XIX	Title XXI	Private/Other	None	Unknown
Type of Individuals Served	Total Served	%	%	%	%	%
Pregnant Women
Infants < 1 year of age
Children 1 to 22 years of age
Children with Special Health Care Needs
Others
Total

INSTRUCTIONS FOR THE COMPLETION OF FORM 7

NUMBER OF INDIVIDUALS SERVED UNDER TITLE V

[Sec. 506(a)(2)(A)(i-ii)]

Title V citation: [Sec. 506(a)(2)(A)(i-ii)] requires each State to submit an annual report on its activities under Title V. Included in this requirement is the following: “(2) Each annual report...shall include the following information: (A)(i) The number of individuals served by the State under the title (by class of individuals). (ii) The proportion of each class of such individuals which has health coverage.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote.

At the top of the Form, on the Line “Reporting Year”, enter the year for which the data applies.

In column (A) enter the estimated unduplicated count of individuals who received a service from the Title V program that is included in the top three levels of the MCH pyramid, regardless of the primary source of coverage. The fourth, or base level, of the MCH pyramid would generally not contain services and thus would not be included. These services would include all individuals served by total dollars reported on line 8 of Form 2, and may include individuals served by dollars reported on Line 9 of Form 2.

Please note that the figure in the “Title V Total Served” column of the “Infants < 1 year of age” row is related to the “Total Births by Occurrence” line in Form 6, and the “TOTAL INFANTS IN STATE” row in section I of Form 8. While these figures are not expected to match, they should show a fairly close relationship to each other.

In the following columns report by the class of individuals served by the Title V program the percentage of those who have as their primary source of coverage either:

Column B: Title XIX (includes Medicaid expansion under Title XXI)

Column C: Title XXI

Column D: Other (public or private) coverage

Column E: None

Column F: Unknown

These may be estimates. If individuals are covered by more than one source, they should be listed under the column of their primary source.

FORM 8

DELIVERIES AND INFANTS SERVED BY TITLE V

AND ENTITLED TO BENEFITS UNDER TITLE XIX

(By Race and Ethnicity)

[Sec. 506(a)(2)(C-D])

Reporting Year:________

I. UNDUPLICATED COUNT BY RACE

(A)

TOTAL ALL RACES

(B)

White

(C)

Black or African American

(D)

American Indian or Native Alaskan

(E)

Asian

(F)

Native Hawaiian or Other Pacific Islander

(G)

More Than One Race Reported

(H)

Other & Unknown

TOTAL DELIVERIES

IN STATE

TITLE V SERVED

ELIGIBLE FOR TITLE XIX

TOTAL INFANTS IN STATE

TITLE V SERVED

ELIGIBLE FOR TITLE XIX

II. UNDUPLICATED COUNT BY ETHNICITY

(A)

TOTAL

NOT Hispanic or Latino

(B)

TOTAL

Hispanic or Latino

(C)

Ethnicity

Not

Reported

HISPANIC OR LATINO (Sub-categories by country or area of origin)

(B.1)

Mexican

(B.2)

Cuban

(B.3)

Puerto

Rican

(B.4)

Central and South American

(B.5)

Other and Unknown

TOTAL DELIVERIES IN STATE

TITLE V SERVED

ELIGIBLE FOR TITLE XIX

TOTAL INFANTS IN STATE

TITLE V SERVED

ELIGIBLE FOR TITLE XIX

INSTRUCTIONS FOR THE COMPLETION OF FORM 8

DELIVERIES AND INFANTS SERVED BY TITLE V

AND ENTITLED TO BENEFITS UNDER TITLE XIX

Title V Citation: Section 506 (a)(2)(C-D) requires each State to submit an annual report on its activities under Title V. Included in this requirement is the following:

(i) the number of deliveries in the State in the year, and

(ii) the number of such deliveries to pregnant women who were provided prenatal, delivery, or postpartum care under this title or were entitled to benefits with respect to such deliveries under the State plan under title XIX in the year.

(D) Information (by racial and ethnic group) on--

(i) the number of infants under one year of age who were in the State in the year, and

(ii) the number of such infants who were provided services under this title or were entitled to benefits under the State plan under title XIX at any time during the year.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

At the top of the form, on the line “Reporting Year,” enter the year for which the data applies. The same “Reporting Year” is to be used for both parts I and II of this form.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote.

Section I:

“Total Deliveries in State” - In column A enter the number for the population-based total of all deliveries in the State for the reporting year eligible for Title XIX who were provided delivery of services in the reporting year. For columns B-H enter the number of individuals who were eligible by race. In column A, for “Total infants in State,” enter the number of infants who were eligible for Title XIX during the reporting year. (Please note that this figure is related to the “Total Births by Occurrence” line in Form 6, and the “Total infants < 1 year of age” row in Form 7. While these figures are not expected to match, they should show a fairly close relationship to each other). For columns B-H enter the number of infants who were eligible by race.

Section II

States without a significant Hispanic or Latino population should report only Hispanic or Latino, Not Hispanic or Latino, or Ethnicity Not Reported categories in columns A through C. States with a significant Hispanic or Latino population are encouraged to report subcategories by country or area of origin in columns B.1 through B.5. If these columns are used, the total of the populations reported in those columns must equal the population figure in column B.

There will be overlap between the figures listed for “Title V Served” and “Eligible for Title XIX,” because this form asks for all individuals served by Title V and an estimate of all those in the State eligible for Title XIX. The form does not ask for a report on those served by Title V who are also eligible for Title XIX.

FORM 9

STATE MCH TOLL-FREE TELEPHONE LINE DATA FORM

[Secs. 505(a)(5)(E) and 509(a)(8)]

STATE: __________________________

FY____

FY ____

State MCH Toll-Free

“Hotline” Telephone Number

___________

State MCH Toll-Free

“Hotline” Name

___________

Name of Contact Person for

State MCH “Hotline”

___________

Contact Person’s

Telephone Number

___________

Number of calls received

On the State MCH “Hotline”

This reporting period

___________

INSTRUCTIONS FOR THE COMPLETION OF FORM 9

STATE MCH TOLL-FREE TELEPHONE LINE DATA FORM

Title V citations: Section 505(a)(5)(E) and 509(a)(8) state, in part, “the State agency (or agencies) administering the State’s program under this title will provide for a toll-free number (and other appropriate methods) for the use of parents to access information about health care providers and practitioners who provide health care services under this title and Title XIX and about other relevant health and health-related providers and practitioners...”

The Maternal and Child Health Bureau is the designee of the Secretary of the Department of Health and Human Services to carry out the mandate of Section 509(a)(8) of Title V, which requires that a National directory of toll-free numbers be made available to State agencies that administer the State’s Title V programs.

Instructions: Complete all required data cells. If an actual number is not available for line 5, make an estimate. Please explain the estimate in a footnote.

On the line labeled “State” enter the name of your State.

At the top of the first column labeled “FY___” enter the appropriate reporting year and then, in each succeeding column to the right, enter the next year in chronological order.

For each year:

On line 1, enter your State’s toll-free MCH information line telephone number.
On line 2, enter the name of your State’s toll-free information line.
On line 3, enter the name of the person who should be contacted with any concerns about the toll-free line.
On line 4, enter the telephone number of the contact person listed on line 3.
On line 5, for the reporting year only, enter the number of calls your State’s toll-free MCH information number received for the reporting period.

If your State has an additional toll-free telephone number administered by Title V that you wish to report, use an additional copy of this form. The first Form 9 should be for the primary MCH toll-free number for your State.

FORM 10

TITLE V MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT

STATE PROFILE FOR FY____

[Sec. 506(a)(1)]

STATE: __________________________________________

1. State MCH Administration:

Block Grant Funds

2. Federal Allocation (Line 1, Form 2) $_______________________

3. Unobligated balance (Line 2, Form 2) $_______________________

4. State Funds (Line 3, Form 2) $_______________________

5. Local MCH Funds (Line 4, Form 2) $_______________________

6. Other Funds (Line 5, Form 2) $_______________________

7. Program Income (Line 6, Form 2) $_______________________

8. Total Federal-State Partnership (Line 8, Form 2) $_______________________

9. Most significant providers receiving MCH funds: ____________________________________

____________________________________

10. Individuals served by the Title V Program (Col. A, Form 7)

a. Pregnant Women ___________________

b. Infants < 1 year old ___________________

c. Children 1 to 22 years old ___________________

d. CSHCN ___________________

e. Others ___________________

FORM 10 (Continued)

TITLE V MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT

STATE PROFILE

11. Statewide Initiatives and Partnerships:

a. Direct Medical Care and Enabling Services:

b. Population-Based Services:

c. Infrastructure Building Services:

12. The primary Title V Program contact person:

The children with special health care needs (CSHCN) contact person:

State Family or Youth Leader (optional):

INSTRUCTIONS FOR THE COMPLETION OF FORM 10

TITLE V MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT

STATE PROFILE

Title V Citation: Section 506(a)(1) states, in part, “Each State shall prepare and submit to the Secretary annual reports on its activities under this title. Each such report...shall be in such standardized form and contain such information...as the Secretary determines...”

(This summary information is extremely useful as a stand-alone document for those who don’t have the time or desire to read the entire Block Grant Application/Annual Report).

Instructions: A glossary with definitions of terms used in this form is presented in Part Two, Section VIII of this document.

(While this is a “reporting” form certain future year(s) data, as specified in the instructions, will be required for its completion)

Fill in the appropriate fiscal year in the title of the form. Enter the name of your State on the line indicated.

Item 1. State which agency administers the Title V program and provide a brief summary of services included within Title V’s administrative control.

Items 2-8. Complete the items for Block Grant Funds. These figures should correspond with figures that are shown on lines 1 through 6 and line 8 on Form 2.

Item 9. List a few of the most significant providers to the community and State receiving MCH funds for the provision of key MCH services.

Item 10. (Items a through e) - Enter the figures for the populations served by the Title V program. These figures should be the same as shown in Column A of Form 7.

Item 11. Complete 2 to 4 short (3 or 4 sentences) examples of statewide initiatives, public health activities, or community-based efforts for each level of the pyramid (6 to 12 examples total). These descriptions should include particularly successful programs or activities that were either provided directly, or coordinated by Title V. Begin each example with a brief title of the program activity followed by the description.

Item 12. Enter the name of the primary Title V program contact. Include title, address, telephone number, FAX number, e-mail address, and Title V program Web site address, if available.

Item 13. Enter the name of the primary CSHCN program contact. Include title, address, telephone number, FAX number, e-mail address, and CSHCN program Web site address, if available.

Item 14. (Optional) Enter the name of the State Family or Youth Leader. Include title, address, telephone number, FAX number, e-mail address, and CSHCN program Web site address, if available.

FORM 11

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #1

The percent of screen positive newborns who received timely follow up to definitive diagnosis and clinical management for condition(s) mandated by their State-sponsored newborn screening programs.

FY__

FY__

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #2

The percent of children with special health care needs age 0 to 18 whose families partner in decision-making at all levels and are satisfied with the services they receive (CSHCN Survey)

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #3

The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing, comprehensive care within a medical home. (CSHCN Survey)

______

_____

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #4

The percent of children with special health care needs age 0 to 18 whose families have adequate private and/or public insurance to pay for the services they need. (CSHCN Survey)

FY__

FY__

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #5

The percent of children with special health care needs age 0 to 18 whose families report the community-based service systems are organized so they can use them easily. (CSHCN Survey)

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #6 (Please refer to the instructions for this Performance Measure)

The percentage of youth with special health care needs who received the services necessary to make transitions to all aspects of adult life, including adult health care, work, and independence. (CSHCN Survey)

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #7

Percent of 19 to 35 month olds who have received full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilis Influenza, Hepatitis B.

FY__

FY__

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #8

The birth rate (per 1,000) for teenagers aged 15 through 17 years.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #9

Percent of third grade children who have received protective sealants on at least one permanent molar tooth.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #10

The rate of deaths to children aged 14 years and younger caused by motor vehicle crashes per 100,000 children.

FY__

FY__

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE # 11

The percent of mothers who breastfeed their infants at 6 months of age.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #12

Percentage of newborns who have been screened for hearing before hospital discharge.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #13

Percent of children without health insurance.

FY__

FY__

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #14

Percentage of children, ages 2 to 5 years, receiving WIC services with a Body Mass Index (BMI) at or above the 85th percentile.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #15

Percentage of women who smoke in the last three months of pregnancy.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #16

The rate (per 100,000) of suicide deaths among youths aged 15-19.

FY__

FY__

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #17

Percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

PERFORMANCE MEASURE #18

Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester.

Annual Performance Objective

______

_____

Annual Performance Indicator

______

_____

Numerator

______

_____

Denominator

______

_____

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #	FY__	FY__	FY__	FY__	FY__
Annual Performance Objective	______	______	______	______	______
Annual Performance Indicator	______	______	______	______	______
Numerator	______	______	______	______	______
Denominator	______	______	______	______	______

INSTRUCTIONS FOR THE COMPLETION OF FORM 11

PERFORMANCE MEASURE TRACKING

Title V Citation: Section 505(a)(2)(B)(i & iii) requires the States to submit an application that includes, A...a statement of the goals and objectives consistent with the health status goals and national health objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of services to be provided... “Section 506(a)(2)(A)(iii) requires the States to report annually on the A...type (as defined by the Secretary) of services provided under this title...”

General Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote. If neither actual data nor an estimate can be provided, the State must provide a footnote that describes a time framed plan for providing the required data. In such cases the “Annual Performance Objective” and “Annual Performance Indicator,” lines are to be left blank.

This form serves two purposes: to show performance measures with 5-year planned performance objectives (targets) for the application, and performance “Annual Performance Indicator,” values actually achieved each year for the annual report for each National and State “negotiated” performance measure.

Under the applicable “FY” heading, each State will complete the Annual Performance Objectives, the Annual Performance Indicators, and numerator and denominator data for each measure as described below under Specific Instructions. For State “negotiated” measures, enter these data on the form beginning with the first blank Performance Measure area under the National measure(s).

Specific Instructions:

Performance Measures are automatically assigned when State creates the detail sheet (Form 16).

For both National and State measures, in the lines labeled “Annual Performance Objective” enter a numerical value for the target the State plans to meet for the next 5 years. These values may be expressed as a number, a rate, a percentage, or “yes - no.”

For both National and State measures, in the lines labeled “Annual Performance Indicator,” enter the numerical value that expresses the progress the State has made toward the accomplishment of the performance objective for the appropriate reporting year. Note that the indicator data are to go in the year column from which they were actually derived even if the data are a year behind the "reporting" year. This value is to be expressed in the same unit as the performance objective: a number, a rate, a percentage, or a “yes - no.”

If there are numerator and denominator data for the performance measures, enter those data on the appropriate lines for the appropriate fiscal year. If there are no numerator and denominator data leave these lines empty.

For each National and State measure, provide a footnote that identifies the data source for the measure.

Repeat this process for each performance measure. A continuation page is included. If the continuation page is used, be sure to enter the number for each listed performance measure.

VIIA - National Performance Measures Detail Sheets

PERFORMANCE MEASURE

The percent of screen positive newborns who received timely^⁰ follow up to definitive diagnosis and clinical management for condition(s) mandated by their State-sponsored newborn screening programs.

GOAL

To assure all screen positive newborns receive timely follow up to definitive diagnosis and clinical management for condition(s) mandated by their State-sponsored newborn screening programs.

DEFINITION

Numerator: The number of newborns screened and confirmed with condition(s) mandated by the State sponsored newborn screening program that received timely follow-up to definitive diagnosis and clinical management.

Denominator: The number of newborns screened and confirmed with condition(s) mandated by the State sponsored newborn screening program.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 32.2: Increase the proportion of screen-positive children who receive follow-up testing within the recommended time period. (Baseline: 98.3% of screen positive children received follow-up testing within the recommended time period in 2006-2008. Target: 100%)

Related to Objective MICH-32.3 (Developmental): Increase the proportion of children with a diagnosed condition identified through newborn screening who have an annual assessment of services needed and received.

DATA SOURCES and

DATA ISSUES

Data supplied annually by each State to the National Newborn Screening and Genetic Resource Center.

SIGNIFICANCE

Screening programs for newborns and children have been shown to be cost-effective and successful and have been shown to prevent mortality and morbidity. Their success reflects the systems approach from early screening to appropriate early intervention and treatment.

PERFORMANCE MEASURE

The percent of children with special health care needs age 0 to 18 years whose families partner in decision making at all levels and are satisfied with the services they receive. (CSHCN survey)

GOAL

To increase the number of families with CSHCN who partner in decision making and are satisfied with the services they receive.

DEFINITION

Numerator: The number of children with special health care needs in the State age 0 to 18 whose families report participating in decision making and being satisfied with the services they received during the reporting period.

Denominator: The number of children with special health care needs in the State age 0 to 18 during the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 31: Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems. (Baseline: 20.4% of children aged 0 through 11 with special health care needs in 2005-2006, Target: 22.4%; and Baseline: 13.8% of children aged 12 through 17 with special health care needs in 2005-2006, Target: 15.2%)

DATA SOURCES and

DATA ISSUES

The National CSHCN Survey provides State level data on the extent to which families perceive that their doctors make the family feel like a partner and the family is very satisfied with the overall care experience. If State uses another data source, please cite source.

SIGNIFICANCE

Family/professional partnerships have been incorporated into the MCHB Block Grant Application and the MCHB strategic plan. The Omnibus Budget Reconciliation Act of 1989 (OBRA ’89) mandated that the States provide and promote family centered, community-based, coordinated care. Family satisfaction is also a crucial measure of system effectiveness.

PERFORMANCE MEASURE

The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing, comprehensive care within a medical home. (CSHCN Survey)

GOAL

To increase the number of children with special health care needs who have a medical home.

DEFINITION

Numerator: The percent of children with special health care needs in the State age 0 to 18 who have a medical home during the reporting period.

Denominator: The number of children with special health care needs in the State age 0 to 18 during the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 30.2: Increase the proportion of children with special health care needs who have access to a medical home. (Baseline: 49.8% of children under age 18 with special health care needs had access to a medical home in 2007, Target 54.8%)

Related to Objective MICH-31: Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems. (Baseline: 20.4% of children aged 0 through 11 with special health care needs in 2005-2006, Target: 22.4%; and Baseline: 13.8% of children aged 12 through 17 with special health care needs in 2005-2006, Target 15.2%)

DATA SOURCES and

DATA ISSUES

The National CSHCN Survey will provide State and National level data on the extent to which families perceive that their child with a special health care need has access to a medical home. Indicators include having a regular doctor for routine and sick care: access to care that is coordinated with specialty care and community services; ease in obtaining referrals: and receipt of respectful and culturally competent care.

The National CSHCN Survey, conducted every four years, provides National and State estimates. If State uses another data source, please cite source.

SIGNIFICANCE

Providing primary care to children in a “medical home” is the standard of practice. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care and immunizations, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions. The MCHB uses the American Academy of Pediatrics (AAP) definition of “medical home.” (AAP Medical Home Policy Statement, presented in Pediatrics, Vol. 110 No. 1, July, 2002)

PERFORMANCE MEASURE

The percent of children with special health care needs age 0 to 18 whose families have adequate private and/or public insurance to pay for the services they need. (CSHCN Survey)

GOAL

To increase the percent of children with special health care needs, age 0 to 18, with adequate insurance coverage for all the services they need.

DEFINITION

Numerator: Number of children with special health care needs in the State age 0 to 18 whose families perceive that they have adequate insurance coverage.

Denominator: Number of children with special health care needs in the State age 0 to 18 during the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Access to Health Services Objective 1: Increase the proportion of persons with health insurance. (Baseline: 83.2% of persons had medical insurance in 2008, Target 100%)

Related to Maternal, Infant, and Child Health (MICH) Objective 31: Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems. (Baseline: 20.4% of children aged 0 through 11 with special health care needs in 2005-2006, Target 22.4%; and Baseline: 13.8% of children aged 12 through 17 with special health care needs in 2005-2006, Target 15.2%)

DATA SOURCES and

DATA ISSUES

The National CSHCN Survey provides State level data on the percent of parents of children with special health care needs reporting private or public health insurance coverage, no gaps in coverage, coverage that meets their child’s needs, reasonable out-of-pocket costs, access to needed providers, and lack of unmet needs due to health plan coverage.

The National CSHCN Survey, conducted every four years, provides National and State estimates.

SIGNIFICANCE

Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive services, less likely to be hospitalized and more likely to be diagnosed early for disabling conditions. Approximately 8.8% of children with special health care needs were uninsured for all or part of the year when surveyed and parents reported approximately one third of insured children with special health care needs had inadequate insurance coverage. (2005-2006 National CSHCN Survey)

PERFORMANCE MEASURE

Percent of children with special health care needs age 0 to 18 whose families report the community-based service systems are organized so they can use them easily. (CSHCN Survey)

GOAL

To increase the number of families with CSHCN who have access to easy-to-use community-based service systems.

DEFINITION

Numerator:

The number of children with special health care needs in the State age 0 to 18 whose families report that community-based service systems are organized so they can use them easily.

Denominator:

The number of children with special health care needs in the State age 0 to 18.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 31: Increase the proportion of children with special health care needs who receive care in family-centered, comprehensive, coordinated systems. (Baseline: 20.4% of children aged 0 through 11 with special health care needs in 2005-2006, Target 22.4%; and Baseline: 13.8% of children aged 12 through 17 with special health care needs in 2005-2006, Target 15.2%)

DATA SOURCES and

DATA ISSUES

The National CSHCN Survey provides State and National level data on the extent to which families perceive that services are organized for easy use.

The National CSHCN Survey, conducted every four years, provides National and State estimates.

SIGNIFICANCE

Families, service agencies and the Federal Interagency Coordinating Council (FICC) have identified major challenges confronting families in accessing coordinated health and related services that families need for their children with special health care needs. Differing eligibility criteria, duplication and gaps in services, inflexible funding streams and poor coordination among service agencies are concerns across most States. Addressing these issues will lead to more efficient use of public funds and reduced family stress.

PERFORMANCE MEASURE

GOAL

To increase the percent of youth with special health care needs who have received the services necessary to make transitions to all aspects of adult life, including adult health care, work, and independence.

DEFINITION

Numerator: Number of youth with special health care needs in the State 18 years of age and younger whose families perceive that they have received the services necessary to transition to adult health care, work, and independence.

Denominator: Number of youth with special health care needs in the State 18 years of age and younger during the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Disability and Health Objective 5: Increase the proportion of youth with special health care needs whose health care provider has discussed transition planning from pediatric to adult health care. (Baseline: 41.2% of youth with special health care needs had health care providers who discussed transition planning from pediatric to adult health care in 2005-2006, Target: 45.3%)

DATA SOURCES and

DATA ISSUES

The National CSHCN Survey provides State and National level data on the percent of parents of children with special health care needs reporting that their child receives support in the transition to adult health care and vocational and career training. This survey, conducted every four years, provides National and State estimates.

SIGNIFICANCE

The transition of youth to adulthood has become a priority issue nationwide as evidenced by the President’s “New Freedom Initiative: Delivering on the Promise” (March 2002). Over 90 percent of children with special health care needs now live to adulthood, but are less likely than their non-disabled peers to complete high school, attend college or to be employed. Health and health care are cited as two of the major barriers to making successful transitions.

PERFORMANCE MEASURE

GOAL

To avert all cases of vaccine-preventable morbidity and mortality in children.

DEFINITION

Numerator: Number of resident children who have received the complete immunization schedule for DTP/DTAP, OPV, measles, mumps, rubella (MMR), H. influenza, and hepatitis B before their second birthday. Complete immunization status is generally considered to be:

3 Hepatitis B
4 DTaP
3 Polio
1 MMR
3 Hib

Denominator: Number of resident children aged 2 years.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Immunization and Infectious Diseases Objective 8: Increase the proportion of children 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella and PCV vaccines. (Baseline: 68% of children aged 19 to 35 months received recommended doses in 2008, Target: 80%)

DATA SOURCES and

DATA ISSUES

State Immunization Registry, CDC National Immunization Survey, State vital records, and U.S. Census Bureau population estimates.

SIGNIFICANCE

Infectious diseases remain important causes of preventable illness in the United States despite significant reductions in incidence in the past 100 years. Vaccines are among the safest and most effective preventive measures.

PERFORMANCE MEASURE

The rate of birth (per 1,000) for teenagers aged 15 through 17 years.

GOAL

To lower the birth rate among teenagers, especially those age 15 through 17 years.

DEFINITION

Numerator: Number of live births to teenagers aged 15-17 years in the calendar year.

Denominator: Number of females aged 15 through 17 years in the calendar year.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Family Planning Objective 8.1: Reduce the pregnancy rate among adolescent females aged 15 to 17 years. (Baseline: 40.2 pregnancies per 1,000 females aged 15 to 17 years in 2005, Target: 36.2 pregnancies per 1,000)

DATA SOURCES and

DATA ISSUES

Vital records are the source of data on mother’s age and births. Population records are available from the U.S. Census Bureau.

SIGNIFICANCE

The Department of Health and Human Services has made the lowering of teen pregnancies (a major threat to healthy and productive lives) a priority goal in strategic planning. Teen parenting is associated with the lack of high school completion and initiating a cycle of poverty for mothers.

PERFORMANCE MEASURE

Percent of third grade children who have received protective dental sealants on at least one permanent molar tooth.

GOAL

To prevent pit and fissure tooth decay (dental caries).

DEFINITION

Numerator: Number of third grade children who have a protective sealant on at least one permanent molar tooth.

Denominator: Number of third grade children in the State during the year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Oral Health Objective 12.2: Increase the proportion of children aged 6 to 9 years who have received dental sealants on one or more of their permanent first molar teeth (Baseline: 25.5% of children aged 6 to 9 years received dental sealants on one or more of their first molar permanent teeth in 1999-2004, Target: 28.1%)

DATA SOURCES and

DATA ISSUES

This requires primary data collection, such as examination or screening of a representative sample of school children.

SIGNIFICANCE

Dental caries affects two-thirds of children by the time they are 15 years of age. Developmental irregularities, called pits and fissures, are the sites of 80-90% of childhood caries. Sealants selectively protect these vulnerable sites, which are found mostly in permanent molar teeth. Targeting sealants to those at greatest risk for caries has been shown to increase their cost-effectiveness. Although sealants have the potential to combine with fluorides to prevent almost all childhood tooth decay, they have been underutilized.

In addition to being an excellent service in preventing tooth decay, sealants may also be a surrogate indicator of dental access, oral health promotion and preventive activities, and a suitable means to assess the linkages that exist between the public and private service delivery systems. Publicly managed sealant programs are usually school-based or school-linked and target underserved children, thus providing entry to other services. It has been stated on several occasions that dental sealants are the oral health equivalent of immunization.

PERFORMANCE MEASURE

The rate of deaths to children aged 14 years and younger caused by motor vehicle crashes per 100,000 children.

GOAL

To reduce the number of deaths to children aged 14 years old and younger caused by motor vehicle crashes.

DEFINITION

Numerator: Number of deaths to children aged 14 years and younger caused by motor vehicle crashes. This includes all occupant, pedestrian, motorcycle, bicycle, etc. deaths caused by motor vehicles.

Denominator: All children in the State aged 14 years and younger.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Injury and Violence Prevention Objective 13.1: Reduce motor vehicle crash related deaths per 100,000 population. (Baseline: 13.8 deaths per 100,000 population by motor vehicle crashes in 2007, Target: 12.4 deaths per 100,000 population)

DATA SOURCES and

DATA ISSUES

Fatal Accident Reporting System (FARS), U.S. Department of Transportation, and Vital Statistics Systems are sources of the data.

SIGNIFICANCE

About 50% of all deaths to children aged 14 years and younger are due to injuries, and around 80% of these are from motor vehicle crashes. Injuries are the leading cause of mortality in this age group and they are one of the most significant health problems affecting the Nation’s children.

PERFORMANCE MEASURE

The percent of mothers who breastfeed their infants at 6 months of age.

GOAL

To increase the percent of mothers who breastfeed their infants at 6 months of age.

DEFINITION

Numerator:

Number of mothers who indicate that breast milk is at least one of the types of food their infant is fed at 6 months of age.

Denominator:

Number of mothers with infants at 6 months of age.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 21.2: Increase the number of infants who are breastfed at 6 months. (Baseline: 43.5% of infants born in 2006 were breastfed at 6 months as reported in 2007-2009, Target: 60.6%)

DATA SOURCES and

DATA ISSUES

CDC’s National Immunization Survey (NIS), CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS), U.S. Department of Agriculture’s WIC Participant and Program Characteristics Study (WIC PC), State WIC Data, and HRSA’s National Survey of Children’s Health (NSCH).

SIGNIFICANCE

Human milk is the preferred feeding for all infants, including premature and sick newborns. Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately thefirst 6 months after birth. The advantages of breastfeeding are indisputable and include nutritional, immunological and psychological benefits to both mother and infant, as well as economic benefits.

Breastfeeding is defined as including any amount of breast milk in the infant’s diet, regardless of additional food substances consumed by an infant.

Exclusive breastfeeding is defined as being fed breast milk or water only. Introduction of other substances to an infant such as formula, cow’s milk, juice and solid foods in addition to breast milk does not qualify as “exclusive” breastfeeding.

PERFORMANCE MEASURE

Percentage of newborns that have been screened for hearing before hospital discharge.

GOAL

To reduce the morbidity associated with hearing impairment through early detection.

DEFINITION

Numerator: The number of newborns in the State whose hearing has been screened before hospital discharge by tests of either otoacoustic emissions or auditory brainstem responses.

Denominator: Number of births in the State in the calendar year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Hearing and Other Sensory or Communication Disorders Objective 1.1: Screen for hearing loss no later than age 1 month. (Baseline: 82.0% of newborns aged 1 month or less had screening for hearing loss in 2007, Target 90.2%)

DATA SOURCES and

DATA ISSUES

State birth certificates, newborn hearing registries, tests of otoacoustic emissions and auditory brainstem responses. Potential data source – State based Early Hearing Detection and Intervention (EHDI) Program Network, CDC.

SIGNIFICANCE

The advantages of early detection of hearing impairments are indisputable and include necessary follow-up of free and appropriate enrollment in habilitation and education programs.

PERFORMANCE MEASURE

Percent of children without health insurance.

GOAL

To ensure access to needed and continuous health care services for children.

DEFINITION

Numerator: Number of children under 18 in the State who are not covered by any private or public health insurance (Including Medicaid or risk pools) at some time during the reporting year.

Denominator: Number of children in the State under 18 (estimated by Census Bureau in March).

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Access to Health Services Objective 1: Increase the proportion of persons with health insurance. (Baseline: 83.2% persons had medical insurance in 2008, Target: 100%)

DATA SOURCES and

DATA ISSUES

The U.S. Census Bureau (American Community Survey, 2009) and the National Survey of Children’s Health provides data on health insurance coverage for children, including the adequacy of insurance coverage by the National Survey of Children’s Health.

SIGNIFICANCE

There is a well documented benefit for children in having health insurance. Research has shown that children who acquire health insurance are more likely to have access to a usual source of care, receive well child care and immunizations, to have developmental milestones monitored, and receive prescriptions drugs, appropriate care for asthma and basic dental services. Serious childhood problems are more likely to be identified early in children with insurance, and insured children with special health care needs are more likely to have access to specialists. Insured children not only receive more timely diagnosis of serious health care conditions but experience fewer avoidable hospitalizations, improved asthma outcomes and fewer missed school days. (Institute of Medicine’s report, America’s Uninsured Crisis: Consequences for Health and Health Care, 2009)

PERFORMANCE MEASURE

Percentage of children, ages 2 to 5 years, receiving WIC services with a Body Mass Index^⁰ (BMI) at or above the 85^th percentile.

GOAL

To reduce the proportion of children, ages 2 to 5 years, who are at risk of overweight or obese.^⁰

DEFINITION

Numerator: The number of children, ages 2 to 5 years, receiving WIC services with a BMI at or above the 85^th percentile.

Denominator: Number of children, ages 2 to 5 years, that receive WIC services during the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Nutrition and Weight Status Objective 10.1: Reduce the proportion of children aged 2 to 5 years who are considered obese. (Baseline: 10.7% of children aged 2 to 5 years were considered obese in 2005-2008, Target: 9.9%)

DATA SOURCES and

DATA ISSUES

State WIC Data, State Program Data (e.g. school surveys, etc.), and HRSA’s National Survey of Children’s Health (NSCH).

SIGNIFICANCE

Childhood overweight/obesity is a serious health problem in the United States, and the prevalence of overweight among preschool children has doubled since the 1970s. There have been significant increases in the prevalence of overweight in children younger than 5 years of age across all ethnic groups. Onset of overweight in childhood accounts for 25 percent of adult obesity; but overweight that begins before age 8 and persists into adulthood is associated with an even greater degree of adult obesity. Childhood overweight is associated with a variety of adverse consequences, including an increased risk of cardiovascular disease, type 2 diabetes mellitus, asthma, social stigmatization, and low self-esteem.

PERFORMANCE MEASURE

Percentage of women who smoke in the last three months of pregnancy.

GOAL

Decrease smoking during pregnancy.

DEFINITION

Numerator: The number of women reporting smoking in the last three months of pregnancy during the calendar year.

Denominator: The number of women delivering babies during the calendar year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 11.3: Increase abstinence from cigarette smoking among pregnant women. (Baseline: 89.6% of females delivering a live birth reported abstaining from smoking cigarettes during pregnancy in 2007, Target: 98.6%)

DATA SOURCES and

DATA ISSUES

Birth certificate. States are encouraged to use U.S. Standard Certificate of Live Birth (revised 11/2003). Pregnancy Risk Assessment Monitoring System (PRAMS).

SIGNIFICANCE

Birth weight is the single most important determinant of a newborn’s survival during the first year. Maternal smoking during pregnancy has been directly related to low birth weight.

PERFORMANCE MEASURE

The rate (per 100,000) of suicide deaths among youths aged 15 through 19.

GOAL

To eliminate self-induced, preventable morbidity and mortality.

DEFINITION

Numerator: Number of deaths attributed to suicide among youths aged 15 through 19.

Denominator: Number of youths aged 15 through 19.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Mental Health and Mental Disorders (MHMD) Objective 1: Reduce the suicide rate. (Baseline: 11.3 suicides per 100,000 in 2007, Target 10.2 suicides per 100,000)

Related to Objective MHMD-2: Reduce suicide attempts by adolescents. (Baseline: 1.9 suicide attempts per 100 occurred in 2009, Target: 1.7 suicide attempts per 100)

DATA SOURCES and

DATA ISSUES

State vital records are the source.

SIGNIFICANCE

Suicide is the third leading cause of death in the United States among youths aged 15 through 19, and in many States it ranks as the second leading cause of death in this population.

PERFORMANCE MEASURE

Percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates.

GOAL

To ensure that higher risk mothers and newborns deliver at appropriate level hospitals.

DEFINITION

Numerator: Number of infants with a birth weight less than 1,500 grams born at sub-specialty facilities (Level III facility).

Denominator: Total number of infants born with a birth weight of less than 1,500 grams.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 33: Increase the proportion of very low birth weight (VLBW) infants born at level III hospitals or subspecialty perinatal centers. (Baseline: 76.1% of VLBW infants were born at level III hospitals or subspecialty perinatal centers in 2008, Target 83.7%)

DATA SOURCES and

DATA ISSUES

Vital records and hospital discharge records.

SIGNIFICANCE

Very low birth weight infants are more likely to survive and thrive if they are born/cared for in an appropriately staffed and equipped facility with a high volume of high-risk admissions.

PERFORMANCE MEASURE

Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester.

GOAL

To ensure early entrance into prenatal care to enhance pregnancy outcomes.

DEFINITION

Numerator: Number of live births with reported first prenatal visit during the first trimester (before 13 weeks’ gestation) in the calendar year.

Denominator: Number of live births in the State in the calendar year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 10.1: Increase the proportion of pregnant women who receive prenatal care beginning in the first trimester. (Baseline: 70.8% of females delivering a live birth received prenatal care beginning in the first trimester in 2007, Target 77.9%)

DATA SOURCES and

DATA ISSUES

Birth certificate data in the State vital records are available for over 99% of births.

SIGNIFICANCE

Early identification of maternal disease and risks for complications of pregnancy or birth are the primary reason for first trimester entry into prenatal care. This can help ensure that women with complex problems and women with chronic illness or other risks are seen by specialists. Early high-quality prenatal care is critical to improving pregnancy outcomes.

FORM 12

TRACKING HEALTH OUTCOME MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

OUTCOME MEASURE 1 CY__ CY__ CY__ CY__ CY__

The infant mortality rate per 1,000 live births.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 2

The ratio of the black infant mortality rate to the white

infant mortality rate.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 3

The neonatal mortality rate per 1,000 live births.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

FORM 12 (Continuation Page)

TRACKING HEALTH OUTCOME MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

OUTCOME MEASURE 4 CY__ CY__ CY__ CY__ CY__

The post-neonatal mortality rate per 1,000 live births.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 5

The perinatal mortality rate per 1,000 live births plus fetal deaths.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 6

The child death rate per 100,000 children aged 1 through14.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

FORM 12

TRACKING HEALTH OUTCOME MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

STATE OUTCOME MEASURE CY__ CY__ CY__ CY__ CY__

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

INSTRUCTIONS FOR THE COMPLETION OF FORM 12

TRACKING HEALTH OUTCOME MEASURES

Title V Citation: Section 505(a)(2)(B)(i & iii) requires the States to submit an application that “…a statement of the goals and objectives consistent with the health status goals and national health objectives…for meeting the needs of specified in the State plan…[and]…an identification of the types of services to be provided…” Section 506(a)(2)(A)(iii) requires the States to report annually on the “…type (as defined by the Secretary) of services provided under this title…”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote.

This form serves two purposes: (1) to show health outcome measures with planned outcome objectives (targets) for the application, and, (2) outcome indicator values actually achieved each year for the annual report.

The “Outcome Measure” titles will already be completed for National Outcome Measures.

On each “Annual Outcome Objective” line, enter a value for the outcome objective the State plans to meet. This value may be expressed as a number, a rate, a percentage, or a “yes – no.”

On each “Annual Outcome Indicator” line, enter the value that expresses the progress the State has made toward the accomplishment of the outcome objective for the appropriate reporting year. This value is to be expressed in the same units as the outcome objective: a number, a rate, a percentage, or a “yes – no.”

Repeat this process for each health outcome measure.

States have the option of adding on State Outcome Measure of their choice. To add a State Outcome Measure, click on the “Add New Outcome Measure” button in TVIS. This will create a blank Form 16 (detail sheet) that will allow you to create a new outcome measure. See the instructions for Form 16, State Performance/Outcome Measure Detail Sheet for more details on that process within TVIS. Complete the remaining columns in the same manner as described above for National Outcome Measures.

VIIB - National Outcome Measures Detail Sheets

OUTCOME MEASURE

The infant mortality rate per 1,000 live births.

GOAL

To reduce the number of infant deaths.

DEFINITION

Numerator: Number of deaths to infants from birth through 364 days of age.

Denominator: Number of live births.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 1.3: Reduce the rate of all infant deaths (within 1 year). (Baseline: 6.7 infant deaths per 1,000 live births within the first year of life in 2006, Target: 6.0 infant deaths per 1,000 live births)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE

The U.S. infant mortality rate has substantially declined over the last century, and has essentially reached a plateau since 2002. In 2007, 29,138 infants died before age one year, representing an infant mortality rate of 6.8 deaths per 1,000 live births. A significant disparity exists in U.S. infant deaths between racial groups, especially for Blacks and American Indians and Alaskan Natives. The non-Hispanic Black infant mortality rate (13.8 deaths per 1,000 live births in 2007) is nearly two and a half times the rate among non-Hispanic Whites and Hispanics. (Child Health USA 2010: Department of Health and Human Services, HRSA) The infant mortality rate in American Indians and Alaskan Natives is approximately one and a half times the rate of non-Hispanic Whites. Infant mortality continues to be an extremely complex health issue with many medical, social, and economic determinants, including race/ethnicity, maternal age, education, smoking and health status.

OUTCOME MEASURE

The ratio of the black infant mortality rate to the white infant mortality rate.

GOAL

To reduce the disparity (ratio) between the black and white infant mortality rates.

DEFINITION

Numerator: The black infant mortality rate per 1,000 live births.

Denominator: The white infant mortality rate per 1,000 live births.

Units: 1 Text: Ratio

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 1.3: Reduce the rate of all infant deaths (within 1 year). (Baseline: 6.7 infant deaths per 1,000 live births within the first year of life-5.57 for whites and 12.9 for blacks in 2006, Target 6.0 infant deaths per 1,000 live births)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE

In 2007, 29,138 infants died before age one year, representing an infant mortality rate of 6.8 deaths per 1,000 live births in the U.S. A significant disparity exists in U.S. infant deaths between racial groups, especially for infants born to non-Hispanic Black women. The non-Hispanic Black infant mortality rate (13.8 deaths per 1,000 live births in 2007) is nearly two and a half times the rate among infants born to non-Hispanic White and Hispanic women. Although the infant mortality rates for Blacks and non-Hispanic Whites have declined over the last century, the disparity between the two racial groups remains essentially unchanged. (Child Health USA 2010: Department of Health and Human Services, HRSA)

Infant mortality continues to be an extremely complex health issue with many medical, social, and economic determinants, including race/ethnicity, maternal age, education, smoking and health status.

OUTCOME MEASURE

The neonatal mortality rate per 1,000 live births.

GOAL

To reduce the number of neonatal deaths.

DEFINITION

Numerator: Number of deaths to infants under 28 days.

Denominator: Number of live births.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 1.4: Reduce the rate of neonatal deaths (within the first 28 days of life). (Baseline: 4.5 neonatal deaths per 1,000 live births occurred within the first 28 days of life in 2006, Target: 4.1 neonatal deaths per 1,000 live births)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE

The U.S. neonatal infant mortality rate in 2007 was 4.4 deaths per 1,000 live births, a slight improvement from the previous year of 4.5 deaths per 1,000 live births. The 2007 neonatal infant mortality rate represented 19,058 infant deaths before 28 days of age. Neonatal mortality is related to gestational age, low birth weight, congenital malformations and health problems originating in the perinatal period, as infections or birth trauma.

A significant disparity exists in neonatal deaths between racial groups, especially for infants born to Black women. The non-Hispanic Black neonatal mortality rate (9.0 deaths per 1,000 live births in 2007) is more than twice the rate among infants born to non-Hispanic White and Hispanic women. (Child Health USA 2010: Department of Health and Human Services, HRSA)

OUTCOME MEASURE

The post-neonatal mortality rate per 1,000 live births.

GOAL

To reduce the number of post-neonatal deaths.

DEFINITION

Numerator: Number of deaths to infants 28 through 364 days of age.

Denominator: Number of live births.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 1.5: Reduce the rate of post-neonatal deaths (between 28 days and 1 year). (Baseline: 2.2 post-neonatal deaths per 1,000 live births occurred between 28 days and 1 year of life in 2006, Target: 2.0 post-neonatal deaths per 1,000 live births)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE

Postneontal mortality is generally related to Sudden Unexpected Infant Death (SUID)/Sudden Infant Death Syndrome (SIDS), unintentional injuries and congenital malformations. In 2007, the U.S. postneonatal mortality rate was 2.3 deaths per 1,000 live births. This represented 10,080 infants that died between 28 days and 1 year of age. The postneonatal mortality rate varies by race and ethnicity with the highest rate in 2007 reported among infants born to non-Hispanic Black women (4.8 per 1,000 live births). The rates among Non-Hispanic White and Hispanic women were 2.0 and 1.9 per 1,000 live births, respectively. (Child Health USA 2010: Department of Health and Human Services, HRSA)

OUTCOME MEASURE

The perinatal mortality rate per 1,000 live births plus fetal deaths.

GOAL

To reduce the number of perinatal deaths.

DEFINITION

Numerator: Number of fetal deaths 28 weeks or more gestation plus early neonatal deaths occurring under 7 days.

Denominator: The number of live births plus fetal deaths.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 1.2: Reduce the rate of fetal and infant deaths during the perinatal period (28 weeks of gestation to 7 days after birth). (Baseline: 6.6 fetal and infant deaths per 1,000 live births and fetal deaths occurred during the perinatal period, 28 weeks gestation to 7 days after birth, in 2005; Target: 5.9 perinatal deaths per 1,000 live births and fetal deaths)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE

Perinatal mortality is a reflection of the health of the pregnant woman and newborn and reflects the pregnancy environment and early newborn care.

OUTCOME MEASURE

The child death rate per 100,000 children aged 1 through 14.

GOAL

To reduce the death rate of children aged 1 through 14.

DEFINITION

Numerator: Number of deaths among children aged 1 through 14 years.

Denominator: Number of children aged 1 through 14.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Related to Maternal, Infant, and Child Health (MICH) Objective 3.1: Reduce the rate of child deaths aged 1 to 4 years. (Baseline: 28.6 deaths among children aged 1 to 4 years per 100,000 population occurred in 2007, Target: 25.7 deaths per 100,000 population)

Related to Objective MICH-3.2: Reduce the rate of child deaths aged 5 to 9 years. (Baseline: 13.7 deaths among children aged 5 to 9 years per 100,000 population occurred in 2007, Target: 12.3 deaths per 100,000 population)

Related to Objective MICH-4.1: Reduce the rate of adolescent deaths aged 10 to 14 years. (Baseline: 16.9 deaths among adolescents aged 10 to 14 years per 100,000 population occurred in 2007, Target: 15.2 deaths per 100,000)

DATA SOURCES and

DATA ISSUES

Child death certificates are collected by State vital records. Data on total number of children comes from the U.S. Census Bureau.

SIGNIFICANCE

In 2007, 10,850 children aged 1 to 14 years died in the U.S. which was an increase of 70 cases over the previous year. The overall mortality rate for children 1 to 4 years was 28.6 per 100,000 children in 2007 and 15.3 per 100,000 for children aged 5 to 14 years. Unintentional injury continues to be the leading cause of death in children 1 to 14 years. Mortality rates were higher among males than females in each age group. Also, child death rates reflect racial/ethnic disparities, with non-Hispanic Black children having considerably higher rates of mortality than children of other racial/ethnic groups. (Child Health USA 2010, Department of Health and Human Services, HRSA)

VIIC - State Outcome Measure Detail Sheet

[If the State has developed an Outcome Measure, insert the completed Detail Sheet in this Section.]

FORM 13

CHARACTERISTICS DOCUMENTING FAMILY PARTICIPATION IN CSHCN PROGRAMS

0 1 2 3*

1. GGGG

Family members participate on advisory committee or task forces and are offering training, mentoring, and reimbursement, when appropriate.

0 1 2 3

GGGG

Financial support (financial grants, technical assistance, travel, and child care) is offered for parent activities or parent groups.

0 1 2 3

3. GGGG

Family members are involved in the Children with Special Health Care Needs elements of the MCH Block Grant Application process.

0 1 2 3

4. GGGG

Family members are involved in service training of CSHCN staff and providers.

0 1 2 3

5. GGGG

Family members are hired as paid staff or consultants to the State CSHCN program (a family member is hired for his or her expertise as a family member.

0 1 2 3

6. GGGG

Family members of diverse cultures are involved in all of the above activities.

____________________________________________________________________________

*0 = Not Met 1 = Partially Met 2 = Mostly Met 3 = Completely Met

INSTRUCTIONS FOR THE COMPLETION OF FORM 13

FAMILY PARTICIPATION IN CHILDREN WITH SPECIAL

HEALTH CARE NEEDS PROGRAMS

Title V Citation: Section 501(a)(1)(D) states in part: That a portion of Title V funds shall be appropriated for the purpose of enabling each State “…to provide and to promote family-centered, community-based, coordinated care (including care coordination services…for children with special health care needs and to facilitate the development of community-based systems of services for such children and their families.)”

The goal of this form is to determine the degree to which family participation exists for the care of children with special health care needs. These are defined as (For planning and systems development) – Those children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. The establishment of systems of services that reflect the principles of comprehensive, community-based, coordinated, family-centered care is essential for effectively fostering and facilitating activities to:

Strengthen the ability of families to care for children with actual or potential chronic and disabling conditions; and
Enable children with special health care needs to remain in the home and community-based living arrangements, rather than in institutional settings.

The completion of the form will assist the Maternal and Child Health Bureau in determining the degree to which families participate in children with special health care needs programs as required by Public Law 101-239. Check the degree to which each describes the State CSHCN program.

Instructions: For each item, on lines 1 through 6, please check the box that best relates the degree which indicates the characteristic that describes the State CSHCN program. The numbers of the boxes represent the degree to which participation have been met.

FORM 14

LIST OF MCH PRIORITY NEEDS

[Sec. 505(a)(1)]

STATE__________________________________ FY_________

Your State’s 5-Year Statewide Needs Assessment should identify the need for preventive and primary care services for pregnant women, mothers, and infants; preventive and primary care services for children; and services for Children with Special Health Care Needs. With each year’s Block Grant application provide a list, (whether or not the priority needs change) of the top maternal and child health needs in your State. Use a simple sentence or phrase to list your State’s needs below. Examples of such statements are: “To reduce the barriers to the delivery of care for pregnant women,” and “The infant mortality rate for minorities should be reduced.”

MCHB will capture annually every State’s top 7 to 10 priority needs in an information system for comparison, tracking, and reporting purposes; you must list at least 7 and the form will only accept up to 10. If desired, the State may list and describe more in a form note. Note that the numbers list below is for computer tracking only and is not meant to indicate a priority order.

10.

FORM 15

TECHNICAL ASSISTANCE (TA) PLANNING

This form should contain a PRELIMINARY listing of the TA that you anticipate requesting for the application year. All TA needs stated on your Block Grant Application/Annual Report may be changed or revised AT ANY TIME during the year. The table below is organized by the following TA categories: 1) General Systems Capacity Issues, 2) State Performance Measure Issues, 3) National Performance Measure Issues, 4) Data-related Issues: Data Systems Development, Needs Assessment, Performance Indicators, and 5) Other. Please see instructions for completing this form on the following page. A glossary of terms applicable to this form is included in Part Two, Section VIII of this document.

*To receive technical assistance, the State must complete and submit a TA Request Form which can be obtained by contacting the assigned MCHB Project Officer.

state _____________________

date _____________________

Category of Technical Assistance Needed	Reason(s) Why Assistance Is Needed	What State, Organization or Individual Would You Suggest Provide the TA (if known)
I. GENERAL SYSTEMS CAPACITY ISSUES
B.
C.

FORM 15 (Continuation Page)

TECHNICAL ASSISTANCE (TA) PLANNING

II. STATE PERFORMANCE MEASURE ISSUES Measure # __.
Measure # __.
Measure # __.
III. NATIONAL PERFORMANCE MEASURE ISSUES Measure # __.
Measure # __.
Measure # __.

FORM 15 (Continuation Page)

TECHNICAL ASSISTANCE (TA) PLANNING

IV. DATA-RELATED ISSUES A. Data System Development
B. Needs Assessment
C. Performance Indicators
V. OTHER A.
B.
C.

INSTRUCTIONS FOR COMPLETION OF FORM 15

TECHNICAL ASSISTANCE (TA) PLANNING

Instructions:

Identify your State and the date of completion on the first page of Form 15.

Enter all anticipated technical assistance needs in the appropriate category. Choose a category from this list:

General Systems Capacity – Assistance needed to improve State’s ability to support services to MCH populations, i.e., workforce training, distance learning, hotlines, etc.
State Performance Measures – Assistance needed to increase State’s ability to meet its objectives for one or more State Performance Measures where performance has not been as strong as desired/expected.
National Performance Measures – Assistance needed to increase State’s ability to meet its objectives for one or more National Performance Measures where performance has not been as strong as desired/expected.
Data Related Issues: Assistance needed to improve State’s ability to collect, tabulate, analyze and report data accurately and reliably, particularly as it relates to Needs Assessment and/or Indicators. In addition, assistance needed to develop data systems or improve data linkages.
Other – Assistance needed in areas not captured by the four main categories mentioned above.

Complete all data cells for each item listed, providing a detailed explanation of why each item of assistance is needed, and if applicable what person(s) or entity the State recommends to provide TA. (Include the performance measure number when applicable.)

NOTE: Formal requests for TA (made later in the year) can be initiated by completing and submitting a Technical Assistance Request Form, which is available from your MCHB Project Officer.

FORM 16

STATE PERFORMANCE/OUTCOME MEASURE DETAIL SHEET

SP# ___________ (Or SO#) PERFORMANCE MEASURE:

GOAL
DEFINITION	Numerator: Denominator: Units: ________ _________ (Number) (Text)
HEALTHY PEOPLE 2020 OBJECTIVE
DATA SOURCES and DATA ISSUES
SIGNIFICANCE

INSTRUCTIONS FOR THE COMPLETION OF FORM 16

STATE PERFORMANCE/OUTCOME MEASURE DETAIL SHEET

Title V Citation: Section 505(a)(2)(B)(i & iii) requires the States to submit an application that includes: “...a statement of the goals and objectives consistent with the health status goals and national health objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of services to be provided...” Section 506(a)(2)(A)(iii) requires the States to report annually on the “...type (as defined by the Secretary) of services provided under this title...”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document. This form is to be used for both State Performance Measures and the additional State Outcome Measure if the State chooses to add one. Complete each section as appropriate for the measure being described.

SP# (or SO#): Enter the number of the State Performance or Outcome Measure

Performance Measure: Enter the narrative description of the performance or outcome measure.

Goal: Enter a short statement indicating what the State hopes to accomplish by tracking this measure.

Definition: Describe how the value of the measure is determined from the data. If the value of the measure is “yes/no” or some other narrative indicator such as “stage 1/stage 2/stage 3," a clear description of what those values mean and how they are determined should be provided.

Numerator: If the measure is a percentage, rate, or ratio, provide a clear description of the numerator.

Denominator: If the measure is a percentage, rate, or ratio, provide a clear description of the denominator.

Units: If the measure is a percentage, rate, ratio, or scale, indicate the units in which the measure is to be expressed (e.g., 1,000, 100) on the "Number" line and type of measure (e.g., percentage, rate, ratio or scale) on "Text" line. If the measure is a narrative, indicate “yes/no” or “stage 1, stage 2", etc. on the "Text" line and make no entry on the "Number" line.

Healthy People 2020 Objective: If the measure is related to a Healthy People 2020 objective describe the objective and corresponding number.

Data Source &Data Issues: Enter the source(s) of the data used in determining the value of the measure and any issues concerning the methods of data collection or limitations of the data used.

Significance: Briefly describe why this measure is significant, especially as it relates to the Goal.

Note that the Performance or Outcome Measure’s title and numerator and denominator data are to appear on Form 11 exactly as they appear on this Form.

FORM 17

HEALTH SYSTEMS CAPACITY INDICATORS

FORMS FOR HSCI 01 THROUGH 04, 07A, 07B & 08 – MULTI-YEAR DATA

Annual Indicator Data

FY __

HEALTH SYSTEMS CAPACITY INDICATOR #01

The rate of children hospitalized for asthma (ICD-9 Codes: 493.0 – 493.9) per 10,000 children less than five years of age.

Annual Indicator

__________

Numerator

__________

Denominator

__________

HEALTH SYSTEMS CAPACITY INDICATOR #02

The percent of Medicaid enrollees whose age is less than one year who received at least one initial or periodic screen.

Annual Indicator

__________

Numerator

__________

Denominator

__________

HEALTH SYSTEMS CAPACITY INDICATOR #03

The percent of CHIP enrollees whose age is less than one year who received at least one periodic screen.

Annual Indicator

__________

Numerator

__________

Denominator

__________

FORM 17 (Continuation Page)

HEALTH SYSTEMS CAPACITY INDICATORS

FORMS FOR HSCI 01 THROUGH 04, 07A, 07B, & 08 – MULTI-YEAR DATA

Annual Indicator Data

FY __

HEALTH SYSTEMS CAPACITY INDICATOR #04

The percent of women (15 through 44) with a live birth during the reporting year whose observed to expected prenatal visits are greater than or equal to 80 percent on the Kotelchuck Index.

Annual Indicator

__________

Numerator

__________

Denominator

__________

HEALTH SYSTEMS CAPACITY INDICATOR #07A

The percent of potentially Medicaid-eligible children, aged 1 to 21 years, who have received a service paid by the Medicaid Program.

Annual Indicator

__________

Numerator

__________

Denominator

__________

HEALTH SYSTEMS CAPACITY INDICATOR #07B

The percent of EPSDT eligible children Medicaid aged 6 through 9 years who have received any dental services during the year.

Annual Indicator

__________

Numerator

__________

Denominator

__________

FORM 17 (Continuation Page)

HEALTH SYSTEMS CAPACITY INDICATORS

FORMS FOR HSCI 01 THROUGH 04, 07A, 07B, & 08 – MULTI-YEAR DATA

Annual Indicator Data

FY __

HEALTH SYSTEMS CAPACITY INDICATOR #08

The percent of State SSI beneficiaries less than 16 years old receiving rehabilitation services from the State Children with Special Health Care Needs (CSHCN Program.

Annual Indicator

__________

Numerator

__________

Denominator

__________

INSTRUCTIONS FOR TRACKING HEALTH SYSTEMS CAPACITY

INDICATORS 01 THROUGH 04, 07A, 07B, AND 08

General Instructions:

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates in a footnote.

The purpose of this form is to show, annually, selected measurements (indicators) of MCH Health Systems Capacity status in the State and to track those indicators over a five year period.

For each of the Health Systems Capacity Indicators, on the lines labeled “Annual Indicator,” enter the numerical value that shows the status for the indicator for the appropriate reporting year. Note that the indicator data is to go in the “years” column from which it was actually derived even if the data is a year behind the “reporting” year. This value is to be expressed in the units that are described on the health status indicator detail sheets which, for these indicators, are either a rate or a percentage.

If there are numerator and denominator data for the indicator value, enter those data on the appropriate lines for the appropriate fiscal year. If actual data is not available for the reporting year, use provisional or estimated numbers for numerator and denominator to generate the indicator value.

Specific Instructions:

Systems Capacity Indicator #01 (Ambulatory Sensitive Condition) There is one part to this indicator. The value is to be expressed as the hospitalization rate per 10,000 children less than 5 years of age.

Systems Capacity Indicator #02 and #03 (Adequacy of Primary Care) The values are to be expressed as percents of Medicaid or CHIP enrollees who received at least one initial or periodic screen in the age ranges indicated.

Systems Capacity Indicator #04 (Prenatal Care Participation) There is one part to this indicator. The value is to be expressed as a percent of women (15 through 44) with a live birth whose observed to expected prenatal visits were greater than or equal to 80 percent on the Kotelchuck Index.

Systems Capacity Indicator #07A (Medicaid Services) There is one part to this indicator. The values are to be expressed as the percent of children who have received any service in the age range indicated.

Systems Capacity Indicator #07B (Medicaid [EPSDT] Dental Health Services) There is one part to this indicator. The values are to be expressed as the percent of children who have received any dental services in the age range indicated.

Systems Capacity Indicator #08 (Direct Health Service) There is one part to this indicator. The values are to be expressed as the percent of State SSI beneficiaries less than 16 years old who are receiving rehabilitative services from the State CSHCN program.

FORM 18
HEALTH SYSTEMS CAPACITY INDICATOR REPORTING FORM - HSCI 05 & 06

HEALTH SYSTEMS CAPACITY INDICATOR #05 (Medicaid and Non-Medicaid Comparison)
INDICATOR #05 Comparison of health system capacity indicators for Medicaid, non-Medicaid, and all MCH populations in the State	YEAR	POPULATION
		MEDICAID*	NON-MEDICAID	ALL
a) Percent of low birth weight (<2,500 grams)  payment source from birth certificate  matching data files
b) Infant deaths per 1,000 live births  payment source from birth certificate  matching data files
c) Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester  payment source from birth certificate  matching data files
d) Percent of pregnant women with adequate prenatal care (observed to expected prenatal visits is greater than or equal to 80% [Kotelchuck Index])  payment source from birth certificate  matching data files
*Please indicate your data source by checking the appropriate box

HEALTH SYSTEMS CAPACITY INDICATOR #06 (Medicaid and CHIP Eligibility Levels)
INDICATOR #06 The percent of poverty level for eligibility in the State’s Medicaid and CHIP programs for infants (0 to 1), children, Medicaid and pregnant women.	YEAR	PERCENT OF POVERTY LEVEL
		MEDICAID	CHIP
a) Infants (0 - 1)
b) Medicaid Children (Age range _____ to _____ ) CHIP Children (Age range _____ to _____ )
c) Pregnant Women

INSTRUCTIONS FOR THE COMPLETION OF

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING FORM - HSCI 05 & 06

General Instructions:

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates in a footnote.

The purpose of this form is to show, annually, selected Medicaid and CHIP indicators in the State. Report these health system capacity indicators every year. Indicator #05 has four parts and indicator #06 has three parts. Specific instructions are:

Specific Instructions:

Health Systems Capacity Indicator #05 (Medicaid and Non-Medicaid Comparison)

In the first column, under the health systems capacity indicator title, check the appropriate box that shows the data source. In the next column enter the specific year for the figures reported. Then:

For #05a, in the appropriate cells, enter the percentage of Medicaid infants, Non-Medicaid infants and all infants born at a low birth weight (<2,500 grams) in the reporting year.

For #05b, in the appropriate cells, enter the rate (per 1,000 infants) of Medicaid infant deaths, Non-Medicaid infant deaths, and all infant deaths in the reporting year.

For #05c, in the appropriate cells, enter the percentage of Medicaid covered infants, Non-Medicaid covered infants and all infants born to pregnant women who entered prenatal care in the first trimester in the reporting year.

For #05d, in the appropriate cells, enter the percentage of Medicaid covered pregnant women, Non-Medicaid covered pregnant women and all pregnant women with adequate prenatal care in the reporting year.

Health Systems Capacity Indicator #06

In the second column enter the specific year for the figures reported. Then:

For #06a, enter the percentages of poverty level required for Medicaid and CHIP program eligibility for all infants 0-1 in the State.

For #06b, enter the percentages of the poverty level required for Medicaid and CHIP program eligibility for all Medicaid and CHIP children in the State. In the first column, under the health systems capacity indicator titles enter the age range used for the reported figures. Note that there can be multiple age ranges.

For #06c, enter the percentages of poverty level required for Medicaid and CHIP program eligibility for pregnant women in the State.

FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING AND TRACKING FORM – HSCI 09A & 09B

General Instructions: The purpose of this form is to show the State MCH data capacity and whether the MCH program has the ability to obtain timely analyses of certain data for programmatic and policy issues. A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.
HEALTH SYSTEMS CAPACITY INDICATOR #09A (General MCH Data Capacity) The ability of the State to assure MCH Program access to policy and program relevant information.
DATABASES OR SURVEYS	Does your MCH program have the ability to obtain data for program planning or policy purpose in a timely manner? (Enter 1-3)*	Does your MCH program have direct access to the electronic database for analysis? (Enter Y/N)
ANNUAL DATA LINKAGES Annual linkage of infant birth and infant death certificates.		
Annual linkage of birth certificates and Medicaid eligibility or paid claims files.		
Annual linkage of birth records and WIC eligibility files.		
Annual linkage of birth records and newborn screening files.		
REGISTRIES AND SURVEYS Hospital discharge survey for at least 90% of in-State discharges.		
Annual birth defects surveillance system.		
Survey of recent mothers at least every two years (like PRAMS).		

*Key: 1 = No, the MCH agency does not have this ability. 2 = Yes, the MCH agency sometimes has this ability, but not on a consistent basis. 3 = Yes, the MCH agency always has this ability.

FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING AND TRACKING FORM – HSCI 09A & 09B

(Continuation Page)

HEALTH SYSTEMS CAPACITY INDICATOR #09B The ability of States to monitor tobacco use by children and youth. (Data Capacity – Adolescent Tobacco Use) The Percent of Adolescents in Grades 9 through 12 Who Reported Using Tobacco Products in the Past Month
DATA SOURCES	Does your State participate in the Youth Risk Behavior Survey (YRBS)? (Enter 1-3)*	Does your MCH program have direct access to the State YRBS database for analysis? (Enter Y/N)
Youth Risk Behavior Surveillance System (YRBSS)		
Other:

*Key: 1 = No. 2 = Yes, the State participates but the sample size is not large enough for valid statewide estimates for this age group. 3 = Yes, the State participates and the sample size is large enough for valid statewide estimates for this age group.

INSTRUCTIONS FOR COMPLETION FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING AND TRACKING FORM – HSCI 09A & 09B

Instructions:

The purpose of Part A of this form is to show, annually, the State MCH data capacity in terms of access to policy and program relevant data in a timely manner and whether the MCH program has direct access to the electronic database for analysis.

= No, the State MCH program the does NOT have the ability to obtain data for program planning or policy purposes in a timely manner.
= Yes, the State MCH program SOMETIMES has the ability to obtain data for program planning or policy purposes in a timely manner.
= Yes, the State MCH program ALWAYS has the ability to obtain data for program planning or policy purposes in a timely manner.

The purpose of Part B of this form is to determine the State’s capacity to monitor Adolescent Tobacco Use by participating in the YRBS or some other similar survey.

= No, the State does NOT participate in the YRBS or a similar survey.
= Yes, the State participates but the sample size is not large enough for valid statewide estimates.
= Yes, the State participates and the sample size is large enough for valid statewide estimates.

VIID - Health Systems Capacity Indicator Detail Sheets

HEALTH SYSTEMS CAPACITY INDICATOR

The rate of children hospitalized for asthma (ICD-9 Codes: 493.0 – 493.9) per 10,000 children less than five years of age.

GOAL

To reduce asthma hospitalization for children less than five years old.

DEFINITION

Numerator: Number of resident asthma (ICD-9 codes: 493.0 – 493.9) hospital discharges for children less than five years old.

Denominator: Estimate of all children less than five years old in the State.

Units: 10,000 Text: Rate per 10,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Respiratory Diseases Objective 2.1: Reduce hospitalizations for asthma of children under age 5 years. (Baseline: 41.4 hospitalizations for asthma per 10,000 children under age 5 years in 2007, Target: 18.1 hospitalizations per 10,000)

DATA SOURCES and

DATA ISSUES

Numerator: State hospital discharge data.

Denominator: State population estimates, U.S. Census Bureau data.

SIGNIFICANCE

Asthma is one of the few medical problems that may be used to measure the extent to which children are receiving quality disease preventive care and health promotion education. Access to and utilization of appropriate medical care can often prevent severe episodes of asthma. Increased asthma hospitalization rates may be a consequence of inadequate outpatient management and diminished access to a medical home.

HEALTH SYSTEMS CAPACITY INDICATOR

The percent Medicaid enrollees whose age is less than one year who received at least one initial or periodic screening.

GOAL

To increase the adequacy of primary care for Medicaid enrollees.

DEFINITION

Numerator: Number of Medicaid enrollees whose age is less than one year during the reporting year who received at least one initial or periodic screen.

Denominator: Number of Medicaid enrollees whose age is less than one year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Access to Health Services (AHS) Objective 7: (Developmental) Increase the proportion of persons who receive appropriate evidence-based clinical preventive services.

Related to Objective AHS-1: Increase the proportion of persons with health insurance. (Baseline: 83.2% of persons had medical insurance in 2008, Target 100%)

DATA SOURCES and

DATA ISSUES

Numerator: State Medicaid claims files or Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program visits for the reporting period.

Denominator: State Medicaid program enrollees for the reporting period. The assumption is that all Medicaid enrollees whose age is less than one year should have at least one initial well child or EPSDT visit.

SIGNIFICANCE

The EPSDT program is a National initiative to provide quality comprehensive services to all Medicaid eligible children. Increasing access to comprehensive, family-centered, community-based, culturally competent care for the medically underserved populations of the State is the first step toward establishing a medical home and a regular source of care.

HEALTH SYSTEMS CAPACITY INDICATOR

The percent Children’s Health Insurance Program (CHIP) enrollees whose age is less than one year who received at least one periodic screen.

GOAL

To increase the adequacy of primary care for CHIP enrollees.

DEFINITION

Numerator: Number of CHIP enrollees whose age is less than one year during the reporting year who received at least one initial or periodic screen.

Denominator: Number of CHIP enrollees whose age is less than one year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Access to Health Services (AHS) Objective 7: (Developmental) Increase the proportion of persons who receive appropriate evidence-based clinical preventive services.

Related to Objective AHS-1: Increase the proportion of persons with health insurance. (Baseline: 83.2% of persons had medical insurance in 2008, Target 100%)

DATA SOURCES and

DATA ISSUES

Numerator: CHIP program claims files for well child visits; or Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program visits for the reporting period.

Denominator: CHIP program enrollees for the reporting period. The assumption is that all CHIP enrollees whose age is less than one year should have at least one initial well child or EPSDT visit.

SIGNIFICANCE

The Children’s Health Insurance Program (CHIP) was established in 1997 to provide health insurance to children in families at or below 200% of the federal poverty level. The program helps States insure low income children who are ineligible for Medicaid but could not afford private insurance. The program was reauthorized with the Child Health Insurance Program (CHIP) Reauthorization Act of 2009, and through the Patient Protection and Affordable Care Act and the Reconciliation Act of 2010 it was extended through 2015. Increasing access to comprehensive, family-centered, community-based, culturally competent care for medically underserved populations of the State is the first step toward establishing a medical home and a regular source of care.

HEALTH SYSTEMS CAPACITY INDICATOR

The percent of women (15 through 44) with a live birth during the reporting year whose observed to expected prenatal visits are greater than or equal to 80 percent on the Kotelchuck Index.

GOAL

To increase the adequacy of prenatal care utilization.

DEFINITION

Numerator: Number of women (15 through 44) during the reporting year whose observed to expected prenatal visits are greater than or equal to 80 percent on the Kotelchuck Index.

Denominator: All women (15 through 44) with a live birth during the reporting year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 10.2: Increase the proportion of pregnant women who received early and adequate prenatal care. (Baseline: 70.5% of pregnant females received early and adequate care in 2007, Target: 77.6%)

DATA SOURCES and

DATA ISSUES

State vital statistics records are sources of this data.

SIGNIFICANCE

Adequate prenatal care is an effective intervention that improves pregnancy outcomes, including reducing infant mortality. The two-part (Kotelchuck) Adequacy of Prenatal Care Utilization Index combines independent assessment of the timing of prenatal care initiation and the frequency of visits received after initiation.

HEALTH SYSTEMS CAPACITY INDICATOR

Comparison of health system capacity indicators for Medicaid, Non-Medicaid, and all MCH populations in the State.

GOAL

To eliminate disparities in pregnancy health outcomes in Medicaid, non-Medicaid, and all populations in the State.

DEFINITION

The table for Health Systems Capacity Indicator 05 is on Form 18 (Medicaid and CHIP data). The table compares low birth weight (<2,500 grams), infant deaths per 1,000 live births, initiation of prenatal care during first trimester of pregnancy, and adequacy of prenatal care (Kotelchuck Index) by the population groups - maternal Medicaid recipient, maternal non-Medicaid recipient, and total maternal population. The table is completed with the appropriate number in the Medicaid, non-Medicaid, and total State population cells for the specified reporting year.

HEALTHY PEOPLE 2020

OBJECTIVE

No specific HP 2020 objective.

DATA SOURCES and

DATA ISSUES

Birth certificates with payment source, linked Medicaid files.

SIGNIFICANCE

Adverse health outcomes disproportionately affect the poor. Enrollment and participation in the State Medicaid, CHIP, or other programs (SNAP, WIC, TANF) may not eliminate the disparity in pregnancy outcomes by socioeconomic status, race and/or ethnicity. The quality of services provided to pregnant women and their newborns should be evaluated to identify barriers to comprehensive, family-centered, community-based, culturally competent care.

HEALTH SYSTEMS CAPACITY INDICATOR

The percent of poverty level for eligibility in the State’s Medicaid and CHIP programs for infants (0 to 1), children, adolescents and pregnant women.

GOAL

To increase State Medicaid and CHIP enrollment for infants (0 to 1), children, adolescents and pregnant women.

DEFINITION

The table for Health Systems Capacity Indicator 06 is on Form 18 (Medicaid and CHIP data). This table has cells for infants (0 to 1), children and adolescents (specify age range), and pregnant women, by year and percent of poverty level required for program eligibility. Complete the cells with the appropriate percentage of poverty level for each of the three groups, and specify the reporting year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Access to Health Services (AHS) Objective 1: Increase the proportion of persons with health insurance. (Baseline: 83.2% of persons had medical insurance in 2008, Target 100%)

Related to Objective AHS-5.2: Increase the proportion of children and youth 17 years and under who have a specific source of ongoing care. (Baseline: 94.3% of children and youth aged 17 years and under had a specific source of ongoing care in 2008, Target 100%)

DATA SOURCES and

DATA ISSUES

State Medicaid and CHIP programs.

SIGNIFICANCE

Adverse health outcomes disproportionately affect the poor. Infants (0 to 1), children, adolescents and pregnant women without private health insurance may not have access to medical care. Participation in the State Medicaid or CHIP programs may positively impact health outcomes. Important features of Maternal and Child Health State program evaluations should include eligibility thresholds, enrollment volume, program retention, transitions in coverage, and access to care.

07A

HEALTH SYSTEMS CAPACITY INDICATOR

Percent of potentially Medicaid-eligible children who have received a service paid by the Medicaid Program.

GOAL

To enroll all Medicaid-eligible children in Medicaid ensuring better access to health care services.

DEFINITION

Numerator: Number of children 1 to 21 years of age who have received a service paid by Medicaid during the Federal fiscal year.

Denominator: The estimated number of children 1 to 21 years of age who are potentially eligible, by State definition, for Medicaid at the end of the Federal fiscal year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Access to Health Services (AHS) Objective 1: Increase the proportion of persons with health insurance. (Baseline: 83.2% of persons had medical insurance in 2008, Target 100%)

DATA SOURCES and

DATA ISSUES

Numerator: The State Medicaid program counts participation monthly and estimates caseload. There are peaks and valleys in participation throughout the year. Most systems do not link the income of the family on the program records, but only the eligibility category (e.g., TANF, expansion, etc.).

Denominator: States may not have these data readily available, and therefore estimates are made by using a variety of data from the Current Population Survey (CPS), State programs, U.S. Census Bureau, and experience.

SIGNIFICANCE

The availability and access to quality health care positively affects the health of the population. This is particularly true for high risk children from low socioeconomic backgrounds or with chronic health conditions. Financial access to health care does not guarantee that all children will enroll and successfully access care, but privately insured children are more likely to receive care.

07B

HEALTH SYSTEMS CAPACITY INDICATOR

The percent of EPSDT eligible children aged 6 through 9 years who have received any dental services during the year.

GOAL

To increase dental health services to Early Periodic Screening, Diagnosis, and Treatment (EPSDT) eligible children aged 6 through 9 years.

DEFINITION

Numerator: Total EPSDT eligible children aged 6 through 9 receiving any dental services in the reporting period.

Denominator: Total children aged 6 through 9 eligible for EPSDT in the State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Oral Health Objective 8: Increase the proportion of low income children and adolescents who received any preventive dental service during the past year. (Baseline: 26.7% of children and adolescents aged 2 to 18 years at or below 200% of the federal poverty level received a preventive dental service during the past year in 2007, Target: 29.4%)

DATA SOURCES and

DATA ISSUES

CMS-416, line 12A (total eligible receiving a dental service) and line 1 (individuals eligible for EPSDT).

SIGNIFICANCE

Dental caries is perhaps the most prevalent disease known. Except in its early stages, it is irreversible and cumulative. Children aged 6 through 8 are at an important stage of dental development. The importance of optimal oral health for these children is not only to their current oral functioning, but also for long-term health. Community water fluoridation, use of preventive services (sealants and topical fluoride treatments) and appropriate oral health behaviors decrease the chance that children will develop caries. Many children, particularly those in high-risk groups, do not receive adequate fluoride exposure or adhesive sealants, regular professional care, or oral hygiene instruction. For children from low-income families, a significant hurdle is paying for services.

HEALTH SYSTEMS CAPACITY INDICATOR

The percent of State SSI beneficiaries less than 16 years old receiving rehabilitation services from the State Children with Special Health Care Needs (CSHCN) Program.

GOAL

For the State CSHCN program to provide rehabilitative services for blind and disabled children less than 16 years old receiving benefits under Title XVI, to the extent medical assistance for such services is not provided by Medicaid.

DEFINITION

Numerator: The number of State SSI beneficiaries less that 16 years old receiving rehabilitative services from the State’s CSHCN program during the Federal fiscal year.

Denominator: The number of SSI beneficiaries less than 16 years old in the State.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

No specific HP 2020 objective.

DATA SOURCES and

DATA ISSUES

State CSHCN and Medicaid programs, and Federal Supplemental Security Income (SSI) program.

SIGNIFICANCE

Title V legislative requirements mandate the provision of rehabilitative services for blind and disabled individuals under the age of 16 receiving benefits under the SSI Program to the extent medical assistance for such services is not provided by promoting family-centered, community-based care. This requirement serves as the basis for States to establish a policy whereby all SSI disabled children are eligible to participate in or benefit from the State Title V CSHCN Program.

09A

HEALTH SYSTEMS CAPACITY INDICATOR

The ability of States to assure Maternal and Child Health (MCH) program access to policy and program relevant information.

GOAL

To assure MCH program and Title V agency access to essential policy and program relevant information from key public health data sets relating to women, children, and families. To demonstrate core MCH data capacity.

DEFINITION

Form 19 for this Health Systems Capacity Indicator is a table with two questions about important databases that document the MCH programs’ ability to obtain essential program and policy relevant information. Following the instructions, enter the degree to which these functions are implemented (1-3) and whether the State MCH program has direct access to the databases (Y/N).

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Public Health Infrastructure (PHI) Objective 10: Increase the number of States that record vital events using the latest U.S. standard certificates and reports.

DATA SOURCES and

DATA ISSUES

The State Title V Agency.

SIGNIFICANCE

To carry out the 10 essential public health services, MCH programs need access to relevant program and policy information. This requires basic data capacity on the part of the Title V agency including the ability to monitor health status, to investigate health problems, and to evaluate programs and policies. One measure of this capacity is the availability and use by State MCH programs of key public health data sets related to women, children, and families.

09B

HEALTH SYSTEMS CAPACITY INDICATOR

The ability of States to monitor tobacco use by children and youth.

GOAL

DEFINITION

Form 19 for this Health Systems Capacity Indicator is a table with two questions about important databases that document the MCH programs’ ability to obtain essential program and policy relevant information. Following the instructions, enter the degree to which the State is participating in the surveys (1-3) and whether the State has direct access to the databases (Y/N).

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Tobacco Use (TU) Objective 20: (Developmental) Increase the number of States and the District of Columbia, Territories and Tribes with sustainable and comprehensive evidence-based tobacco control programs.

DATA SOURCES and

DATA ISSUES

Youth Risk Behavior Surveillance System (YRBSS) or State survey data.

SIGNIFICANCE

FORM 20
HEALTH STATUS INDICATORS #01 - 05
MULTI-YEAR DATA

			Annual Indicator Data

			FY _____	FY _____	FY _____	FY _____	FY _____
HEALTH STATUS INDICATOR #01A (Low Birth Weight)
The percent of live births weighing less than 2,500 grams. (Risk)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

HEALTH STATUS INDICATOR #01A (Low Birth Weight - Singleton Births)
The percent of live singleton births weighing less than 2,500 grams. (Risk)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

FORM 20
HEALTH STATUS INDICATORS #01 - 05
MULTI-YEAR DATA (Continuation Page)

			Annual Indicator Data

			FY _____	FY _____	FY _____	FY _____	FY _____
HEALTH STATUS INDICATOR #02A (Low Birth Weight)
The percent of live births weighing less than 1,500 grams. (Risk)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

HEALTH STATUS INDICATOR #02B (Low Birth Weight - Singleton Births)
The percent of live singleton births weighing less than 1,500 grams. (Risk)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

FORM 20
HEALTH STATUS INDICATORS #01 - 05
MULTI-YEAR DATA (Continuation Page)

			Annual Indicator Data

			FY _____	FY _____	FY _____	FY _____	FY _____
HEALTH STATUS INDICATOR #03A (Fatal Unintentional Injuries)
The death rate per 100,000 due to unintentional injuries among children aged 14years and younger. (Injuries)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

HEALTH STATUS INDICATOR #03B (Fatal Unintentional Injuries)
The death rate per 100,000 for unintentional injuries among children aged 14 years and younger due to motor vehicle crashes. (Injuries)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

HEALTH STATUS INDICATOR #03C (Fatal Unintentional Injuries)
The death rate per 100,000 for unintentional injuries for youth aged 15 through 24 years old due to motor vehicle crashes. (Injuries)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

FORM 20
HEALTH STATUS INDICATORS #01 - 05
MULTI-YEAR DATA (Continuation Page)

			Annual Indicator Data

			FY _____	FY _____	FY _____	FY _____	FY _____
HEALTH STATUS INDICATOR #04A (Nonfatal Unintentional Injuries)
The rate per 100,000 of all nonfatal injuries among children aged 14 years and younger. (Injuries)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

HEALTH STATUS INDICATOR #04B (Nonfatal Unintentional Injuries)
The rate per 100,000 of all nonfatal injuries due to motor vehicle crashes among children aged 14 years and younger (Injuries)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

HEALTH STATUS INDICATOR #04C (Nonfatal Unintentional Injuries)
The rate per 100,000 of all nonfatal injuries due to motor vehicle crashes among youth aged 15 years through 24 years. (Injuries)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

FORM 20
HEALTH STATUS INDICATORS #01 - 05
MULTI-YEAR DATA (Continuation Page)

			Annual Indicator Data

			FY _____	FY _____	FY _____	FY _____	FY _____
HEALTH STATUS INDICATOR #05A (Sexually Transmitted Disease – Chlamydia)
The rate per 1,000 women aged 15 through 19 years with a reported case of chlamydia. (Prevention)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

HEALTH STATUS INDICATOR #05B (Sexually Transmitted Disease – Chlamydia)
The rate per 1,000 women aged 20 through 44 years with a reported case of chlamydia. (Prevention)
	Annual Indicator		_________	_________	_________	_________	_________
		Numerator	_________	_________	_________	_________	_________
		Denominator	_________	_________	_________	_________	_________

FORM 20

HEALTH STATUS INDICATORS

MULTI-YEAR DATA (Continuation Page

Annual Indicator Data
NSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 20

TRACKING HEALTH STATUS INDICATORS #01 THROUGH #05

General Instructions:

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates in a footnote.

The purpose of this form is to show, annually, selected measurements (indicators) of MCH health status in the State and to track those indicators over a five year period. The first five health status indicators deal with data that is to be tracked and displayed over five years. Some of these set of indicators have two or three parts resulting in a total of twelve data elements that are to be completed. Specific instructions, by Health Status Indicator number, are provided below.

For each of the Health Status Indicators, on the lines labeled “Annual Indicator,” enter the numerical value that shows the status for the indicator for the appropriate reporting year. Note that the indicator data is to go in the “years” column from which it was actually derived even if the data is a year behind the “reporting” year. This value is to be expressed in the units that are described on the health status indicator detail sheets which, for these indicators, are either a rate or a percentage.

If there are numerator and denominator data for the indicator value, enter those data on the appropriate lines for the appropriate fiscal year. If there are no numerator and denominator data, leave these lines empty.

Specific Instructions:

Indicator #01 (Low Birth Weight) There are two parts to this indicator (A and B). The values are to be expressed as percents of total or singleton live births weighing less than 2,500 grams.

Indicator #02 (Very Low Birth Weight) There are two parts to this indicator (A and B). The values are to be expressed as percents of total or singleton live births weighing less than 1,500 grams.

Indicator #03 (Fatal Unintentional Injuries) There are three parts to this indicator (A-C). The value is to be expressed as a death rate per 100,000 in the age ranges indicated.

Indicator #04 (Nonfatal Unintentional Injuries) There are three parts to this indicator (A-C). The values are to be expressed as an injury rate per 100,000 in the age ranges indicated.

Indicator #05 (Sexually Transmitted Disease [Chlamydia]) There are two parts to this indicator (A and B). The values are to be expressed as Chlamydia case rates per 1,000 women in the age ranges indicated.

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA - #06 - #12

HSI #06A – Demographics (Total Population) Infants and children aged 0 through 24 years enumerated by sub-populations of age group and race. (Demographics)

For both parts A and B: Reporting Year _________ Is this data from a State Projection?  YES  NO

CATEGORY TOTAL POPULATION BY RACE	TOTAL ALL RACES	WHITE	BLACK OR AFRICAN AMERICAN	AMERICAN INDIAN OR NATIVE ALASKAN	ASIAN	NATIVE HAWAIIAN OR OTHER PAC. IS.	MORE THAN ONE RACE REPORTED	OTHER AND UNKNOWN
Infants 0 to 1
Children 1 through 4
Children 5 through 9
Children 10 through 14
Children 15 through 19
Children 20 through 24
Children 0 through 24

HSI #06B – Demographics (Total Population) Infants and children aged 0 through 24 years enumerated by

sub-populations of age group and ethnicity. (Demographics)

CATEGORY TOTAL POPULATION BY HISPANIC ETHNICITY	TOTAL NOT HISPANIC OR LATINO	TOTAL HISPANIC OR LATINO	EHTNICITY NOT REPORTED
Infants 0 to 1
Children 1 through 4
Children 5 through 9
Children 10 through 14
Children 15 through 19
Children 20 through 24
Children 0 through 24

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA - #06 - #12

(Continuation page)

HSI #07A – Demographics (Total live births) Live births to women (of all ages) enumerated by maternal age and race. (Demographics)

For both parts A and B: Reporting Year _________ Is this data from a State Projection?  YES  NO

CATEGORY TOTAL LIVE BIRTHS BY RACE	TOTAL ALL RACES	WHITE	BLACK OR AFRICAN AMERICAN	AMERICAN INDIAN OR NATIVE ALASKAN	ASIAN	NATIVE HAWAIIAN OR OTHER PAC. IS.	MORE THAN ONE RACE REPORTED	OTHER AND UNKNOWN
Women <15
Women 15 through 17
Women 18 through 19
Women 20 through 34
Women 35 or older
Women of all ages

HSI #07B – Demographics (Total live births Live births to women (of all ages) enumerated by maternal age

and ethnicity. (Demographics)

CATEGORY TOTAL POPULATION BY HISPANIC ETHNICITY	TOTAL NOT HISPANIC OR LATINO	TOTAL HISPANIC OR LATINO	EHTNICITY NOT REPORTED
Women <15
Women 15 through 17
Women 18 through 19
Women 20 through 34
Women 35 or older
Women of all ages

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA - #06 - #12

(Continuation page)

HSI #08A – Demographics (Total deaths) Deaths of infants and children aged 0 through 24 years enumerated by age subgroup and race. (Demographics)

For both parts A and B: Reporting Year _________ Is this data from a State Projection?  YES  NO

CATEGORY TOTAL DEATHS BY RACE	TOTAL ALL RACES	WHITE	BLACK OR AFRICAN AMERICAN	AMERICAN INDIAN OR NATIVE ALASKAN	ASIAN	NATIVE HAWAIIAN OR OTHER PAC. IS.	MORE THAN ONE RACE REPORTED	OTHER AND UNKNOWN
Infants 0 to 1
Children 1 through 4
Children 5 through 9
Children 10 through 14
Children 15 through 19
Children 20 through 24
Infants and children 0 through 24

HSI #08B – Demographics (Total deaths) Deaths of infants and children aged 0 through 24 years enumerated by

age subgroup and ethnicity. (Demographics)

CATEGORY TOTAL DEATHS BY HISPANIC ETHNICITY	TOTAL NOT HISPANIC OR LATINO	TOTAL HISPANIC OR LATINO	EHTNICITY NOT REPORTED
Infants 0 to 1
Children 1 through 4
Children 5 through 9
Children 10 through 14
Children 15 through 19
Children 20 through 24
Infants and Children 0 - 24

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA - #06 - #12

(Continuation page)

HSI #09A – Demographics (Miscellaneous Data) Infants and children aged 0 through 19 years in miscellaneous situations or enrolled in various State programs enumerated by race. (Demographics)

CATEGORY MISCELLANEOUS DATA BY RACE	TOTAL ALL RACES	WHITE	BLACK OR AFRICAN AMERICAN	AMERICAN INDIAN OR NATIVE ALASKAN	ASIAN	NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	MORE THAN ONE RACE REPORTED	OTHER AND UNKNOWN	SPECIFIC REPORTING YEAR
All children 0 through 19
Percent in household headed by single parent
Percent in TANF (Grant) families
Number enrolled in Medicaid
Number enrolled in CHIP
Number living in foster home care
Number enrolled in SNAP program
Number enrolled in WIC
Rate (per 100,000) of juvenile crime arrests
Percentage of high school drop-outs (grade 9 through 12)

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA - #06 - #12

(Continuation page)

HSI #09B – Demographics (Miscellaneous Data) Infants and children aged 0 through 19 years in miscellaneous situations

or enrolled in various State programs enumerated by ethnicity. (Demographics)

CATEGORY MISCELLANEOUS DATA BY HISPANIC ETHNICITY	TOTAL NOT HISPANIC OR LATINO	TOTAL HISPANIC OR LATINO	ETHNICITY NOT REPORTED	SPECIFIC REPORTING YEAR
All children 0 through 19
Percent in household headed by single parent
Percent in TANF (Grant) families
Number enrolled in Medicaid
Number living in foster home care
Number enrolled in CHIP
Number enrolled in SNAP program
Number enrolled in WIC
Rate (per 100,000) of juvenile crime arrests
Percentage of high school drop-outs (grade 9 through 12)

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA - #06 - #12

(Continuation page)

HSI #10 – Demographics (Geographic Living Area) Geographic living

area for all resident children aged 0 through 19 years old. (Demographics)

Reporting Year _________ Is this data from a State Projection?  YES  NO

GEOGRAPHIC LIVING AREAS	TOTAL
Living in metropolitan areas
Living in urban areas
Living in rural areas
Living in frontier areas
Total – all children 0 through 19

HSI #11 – Demographics (Poverty Levels) Poverty levels for the total State Population.(Demographics)

Reporting Year _________ Is this data from a State Projection?  YES  NO

POVERTY LEVELS	TOTAL
Total Population
Percent Below: 50% of poverty
100% of poverty
200% of poverty

HSI #12 – Demographics (Poverty Levels) Poverty levels for all children aged 0

through 19 years.(Demographics)

Reporting Year _________ Is this data from a State Projection?  YES  NO

POVERTY LEVELS	TOTAL
Children 0 through 19 years old
Percent Below: 50% of poverty
100% of poverty
200% of poverty

INSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 21
HEALTH STATUS INDICATORS #06 THROUGH #12

General Instructions:

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

The purpose of this form, which contains 11 tables for 6 indicators, is to provide, annually, selected demographic data in the State. Indicators 6, 7, 8, and 9each have two parts (A and B) and indicators 10, 11, and 12 each have one part. The racial and ethnic population categories included in these tables are from the most current Office of Management and Budget guidelines.

At the top of each table [EXCEPT FOR THE TABLES FOR HSI 09A and 09B enter the year for which the data is being reported and check the appropriate box to indicate if the data is from a State projection. For Health Status Indicators 6 through 8 the Reporting Year will be the same for parts A and B of each form. See specific instructions below for dating the data on tables HSI 09A and 09B.

Specific Instructions:

Health Status Indicators 06-12 (Demographics)

For Table #06A (Total Population): In the column labeled “TOTAL ALL RACES” enter the total population of the State in the age groups specified. In the next seven columns enter the population of the State in the racial categories indicated at the head of each column and in the age groups specified. In the column headed “MORE THAN ONE RACE REPORTED” enter the population figure for instances where more than one race is reported. In the column headed “OTHER AND UNKNOWN” enter the population figure for other racial categories not shown and/or population figures where the racial category is not known. The population figures in the columns for the racial categories must equal the figures in the “TOTAL ALL RACES” column.

For Table #06B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the total of the population of the State, in the age groups specified, that are not of Hispanic or Latino ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the total population figures for those that are of Hispanic or Latino ethnicity. IN the column headed “EHTNICITY NOT REPORTED” enter the total of the population whose ethnicity is not reported. The sum of these three figures must equal the figures in the “TOTAL ALL RACES’ column of Table 06A.

INSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 21
HEALTH STATUS INDICATORS #06 THROUGH #12 (Continued)

For Table #07A (Total live births): In the column labeled “TOTAL ALL RACES” enter the number of live births in the Sate for the age groups specified. IN the next seven columns enter the number of live births in the racial categories indicated at the head of each column and in the age groups specified. In the column headed “MORE THAN ONE RACE REPORTED” enter the number of live births for instances where more than one race is reported. In the column headed “OTHER AND UNKNOWN” enter the number of live births for other racial categories not shown and/or live birth figures where the racial category is not known. The live birth figures in the columns for the racial must equal the figures in the “TOTAL ALL RACES” column.

For Table #07B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the number of live births in the State, in the age groups specified, that are not of Hispanic or Latino ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the number of live births for the population that are of Hispanic or Latino ethnicity. In the column headed “ETHNICITY NOT REPORTED” enter live birth figures for the total of the population whose ethnicity is not reported. The sum of these three figures must equal the figures in the “TOTAL ALL RACES” column of Table 07A.

For Table #08A (Total deaths): In the column labeled “TOTAL ALL RACES” enter the number of deaths to infants and children in the State for the age groups specified. In the next seven columns enter the number of deaths to infants and children in the racial categories indicated at the head of each column and in the age groups specified. In the column headed “MORE THAN ONE RACE REPORTED” enter the number of deaths to infants and children for instances where more than one race is reported. In the column headed “OTHER AND UNKNOWN” enter the number of deaths to infants and children for other racial categories not shown and/or infant/child death figures where the racial category is not known. The infant/child death figures in the columns for the racial categories must equal the figures in the “TOTAL ALL RACES’ column.

For Table #08B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the number of deaths to infants and children in the State, in the age groups specified, that are not of Hispanic ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the infant/child death figures for those that are of Hispanic or Latino ethnicity. In the column headed “ETHNICITY NOT REPORTED” enter the population data for those instances where the ethnic category is not reported.

For Table #09A (Miscellaneous Data): In the column labeled “ALL RACES” enter the population data requested for the categories listed in the first column. IN the next seven columns enter the population data for the categories listed and for the racial categories indicated at the head of each column. In the column headed “MORE THAN ONE RACE REPORTED” enter the population data for the categories listed where more than one race is reported. In the column headed “OTHER AND UNKNOWN” enter the population data for the categories listed for other racial categories not shown and/or for those instances where the racial category is not known. Enter in the column headed “SPECIFIC REPORTING YEAR” the year for which the data is reported.

For Table #09B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the population data for the categories listed in the first column that are not of Hispanic or Latino ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the population data for those that are of Hispanic or Latino ethnicity. In the column headed “ETHNICITY NOT REPORTED” enter the population data for those instances where the ethnic category is not reported. Enter in the column headed “SPECIFIC REPORTING YEAR” the year for which the data is reported.

INSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 21
HEALTH STATUS INDICATORS #06 THROUGH #12 (Continued)

For Table #10 (Geographic Living Area):

In the second column of the first four rows enter the number of children aged 0 through 19 residing in the State for each geographic region listed in the first column. If the State already has figures for these geographic breakouts they may use those. In such cases specify in a footnote the parameters that are used for the geographic locations. For States that do not have these breakouts, the following information is provided:

METROPOLITAN areas are defined by the Office of Management and Budget (OMB) according to published standards that are applied to U.S. Census Bureau data. The most current list of Metropolitan Areas is available in PDF downloadable file format - http://www.census.gov/population/metro/data/def.html

URBAN areas are defined by the U.S. Census Bureau and can be found at http://www.census.gov/geo/www/ua/2010urbanruralclass.html. For the 2010 Census, an urban area will comprise a densely settled core of census tracts and/or census blocks that meet minimum population density requirements, along with adjacent territory containing non-residential urban land uses as well as territory with low population density included to link outlying densely settled territory with the densely settled core. To qualify as an urban area, the territory identified according to criteria must encompass at least 2,500 people, at least 1,500 of which reside outside institutional group quarters. The Census Bureau identifies two types of urban areas:

Urbanized Areas (UAs) of 50,000 or more people;
Urban Clusters (UCs) of at least 2,500 and less than 50,000 people.

RURAL areas are defined as territory, population, and housing units not classified as urban.

FRONTIER areas, for the purposes of this table, are defined as counties with population densities of 6 persons or fewer per square mile.

In the second column of the last row enter the total State population of children aged 0 through 19.

For Table #11 (Poverty Levels – Total Population)

In the second cell of the first row enter the total of the State population living at or below the Federal Poverty Level. In the second cell of the remaining rows enter the percent of the total population living at or below the percentages indicated in the first column.

For Table #12 (Poverty Levels – Children 0 through 19)

In the second cell of the first row enter the number of the State population aged 0 through 19 living at or below the Federal Poverty Level. In the second cell of the remaining rows enter the percent of the State population aged 0 through 19 living at or below the percentages indicated in the first column.

VIIE - Health Status Indicators Detail Sheets

01A

HEALTH STATUS INDICATOR

The percent of live births weighing less than 2,500 grams.

GOAL

To reduce proportion of all live deliveries with low birth weight.

DEFINITION

Numerator: Number of resident live births less than 2,500 grams.

Denominator: Number resident live births in the State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 8.1: Reduce low birth weight (LBW). (Baseline: 8.2% of live births were LBW in 2007, Target 7.8%)

DATA SOURCES and

DATA ISSUES

State vital records and Census Bureau data are source.

SIGNIFICANCE

The general category of low birth weight infants includes pre-term infants and infants with intrauterine growth retardation. Many risk factors have been identified for low birth weight babies including: both young and old maternal age, poverty, late prenatal care, smoking, substance abuse, and multiple births. In vitro fertilization has increased the number of multiple births. Multiple births often result in shortened gestation and low or very low birth weight infants.

01B

HEALTH STATUS INDICATOR

The percent of live singleton births weighing less than 2,500 grams.

GOAL

To reduce the proportion of all live singleton deliveries with low birth weight.

DEFINITION

Numerator: Number of resident live singleton births weighing less than 2,500 grams.

Denominator: Number of resident live singleton births in the State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 8.1: Reduce low birth weight (LBW). (Baseline: 8.2% of live births were LBW in 2007, Target 7.8%)

DATA SOURCES and

DATA ISSUES

State vital records and Census Bureau data are source.

SIGNIFICANCE

Low birth weight infants are about 25 times more likely to die during the first year of life than are infants of normal weight (at least 5.5 pounds). They are also at greater risk of physical and developmental health problems in both the short and long term.

02A

HEALTH STATUS INDICATOR

The percent of live births weighing less than 1,500 grams.

GOAL

To reduce proportion of all live deliveries with very low birth weight.

DEFINITION

Numerator: Number of resident live births weighing less than 1,500 grams.

Denominator: Number of resident live births in the State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 8.2: Reduce very low birth weight (VLBW). (Baseline: 1.5% of live births were VLBW in 2007, Target 1.4%)

DATA SOURCES and

DATA ISSUES

State vital records and Census Bureau data are source.

SIGNIFICANCE

Very low birth weight births are usually associated with pre-term birth. The primary risk factors for pre-term births are prior preterm birth, prior spontaneous abortion, low pre-pregnancy weight, cigarette smoking, and multiple births. In vitro fertilization has increased the number of multiple births. Multiple births may result in shortened gestation and low or very low birth weight infants.

02B

HEALTH STATUS INDICATOR

The percent of live singleton births weighing less than 1,500 grams.

GOAL

To reduce the proportion of all live singleton deliveries with very low birth weight.

DEFINITION

Numerator: Number of resident singleton births weighing less than 1,500 grams.

Denominator: Number resident singleton births in the State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 8.2: Reduce very low birth weight (VLBW). (Baseline: 1.5% of live births were VLBW in 2007, Target 1.4%)

DATA SOURCES and

DATA ISSUES

State vital records and Census Bureau data are source.

SIGNIFICANCE

VLBW infants are more than 100 times more likely to die in the first year of life than are infants of normal birth weight (at least 5.5 pounds). Very low birth weight infants who survive are at a significantly increased risk of severe health and developmental problems, including physical and sensory difficulties, developmental delays, and cognitive impairment, which may require increased levels of medical, educational, and parental care.

03A

HEALTH STATUS INDICATOR

The death rate per 100,000 due to unintentional injuries among children aged 14 years and younger.

GOAL

To reduce the number of deaths among children aged 14 years and younger due to unintentional injuries.

DEFINITION

Numerator: Number of deaths from all unintentional injuries for children aged 14 years and younger.

Denominator: Number of children aged 14 years and younger in the State for the reporting period.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 11: Reduce unintentional injury deaths. (Baseline: 40.0 deaths per 100,000 population caused by unintentional injuries in 2007, Target: 36.0 deaths per 100,000 population)

DATA SOURCES and

DATA ISSUES

Child death certificates are collected in State vital records. Data on total number of children comes from the U.S. Census Bureau. The Fatality Analysis Reporting System (FARS), the U.S. Department of Transportation and Vital Statistics Systems are additional sources.

SIGNIFICANCE

Unintentional injury remains the leading cause of death among children aged 1-14 years, accounting for over one third of all childhood deaths. Motor vehicle crashes, drowning, suffocation, fires/burns and pedestrian related accidents are the leading causes of childhood injury deaths. (Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 2007)

03B

HEALTH STATUS INDICATOR

The death rate per 100,000 for unintentional injuries among children aged 14 years and younger due to motor vehicle crashes.

GOAL

To reduce the number of deaths to children aged 14 years and younger due to motor vehicle crashes.

DEFINITION

Numerator: Number of unintentional fatalities to children aged 14 years and younger from motor vehicle crashes in the reporting year.

Denominator: Number of children aged 14 years and younger in the State in the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 13.1: Reduce motor vehicle deaths per 100,000 population. (Baseline: 13.8 deaths per 100,000 population caused by motor vehicle crashes in 2007, Target: 12.4 deaths per 100,000 population)

DATA SOURCES and

DATA ISSUES

SIGNIFICANCE

Unintentional injury remains the leading cause of death among children aged 1-14 years, accounting for over one third of all childhood deaths. Among 5-14 year old children, motor vehicle traffic deaths was the leading cause of unintentional injury deaths, accounting for 53 % of these deaths. Among 1-4 year old children motor vehicle traffic deaths accounted for 29 % for unintentional injury deaths. (Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 2007)

03C

HEALTH STATUS INDICATOR

The death rate per 100,000 for unintentional injuries for youth aged 15 through 24 years old due to motor vehicle crashes.

GOAL

To reduce the number of deaths to youth aged 15 through 24 years due to motor vehicle crashes.

DEFINITION

Numerator: Number of unintentional fatalities to youth aged 15 through 24 years due to motor vehicle crashes in the reporting year.

Denominator: Number of youths aged 15 through 24 years in the State in the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

DATA SOURCES and

DATA ISSUES

Child deaths certificates are collected in State vital records. Data on total number of children comes from the U.S. Census Bureau. The Fatality Analysis Reporting System (FARS), the U.S. Department of Transportation and Vital Statistics Systems are further sources.

SIGNIFICANCE

Injuries are the leading cause of death among persons aged 1 through 34 years and a significant health problem affecting the Nation’s children. Motor vehicle crashes are the leading cause of death among those 5 to 34 years old (CDC, National Center for Injury Prevention and Control, http://www.cdc.gov/injury/).

04A

HEALTH STATUS INDICATOR

The rate per 100,000 of all nonfatal injuries among children aged 14 years and younger.

GOAL

To reduce the number of hospitalizations of children aged 14 years and younger due to nonfatal injuries.

DEFINITION

Numerator: Number of children aged 14 years and younger who have a hospital discharge for nonfatal injuries.

Denominator: Number of children aged 14 years and younger in the State for the reporting period.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 1.2: Reduce hospitalization for nonfatal injuries. (Baseline: 617.6 hospitalizations for nonfatal injuries per 100,000 population occurred in 2007, Target: 555.8 hospitalizations per 100,000 population)

DATA SOURCES and

DATA ISSUES

Numerator: State E-coded hospital discharge data.

Denominator: Census Bureau data, State population estimates.

Potential Data Source: National Hospital Discharge Survey (NHDS), Centers for Disease Control and Prevention, NCHS.

SIGNIFICANCE

Among U.S. children, injury remains the leading cause of morbidity and mortality. It is estimated that 9.2 million children have an initial emergency department visit each year because of unintentional injuries. Annually, childhood injuries requiring medical attention cost 17 billion dollars in health care costs. (Centers for Disease Control and Prevention: Childhood Injury Report, 2000-2006)

04B

HEALTH STATUS INDICATOR

The rate per 100,000 of nonfatal injuries due to motor vehicle crashes among children aged 14 years and younger.

GOAL

To reduce the number of hospitalizations among children aged 14 years and younger due to motor vehicle crashes.

DEFINITION

Numerator: Number of children aged 14 years and younger with a hospital discharge for nonfatal injuries due to motor vehicle crashes in the reporting year.

Denominator: Number of children aged 14 years and younger in the State for the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 14: Reduce nonfatal motor vehicle crash-related injuries. (Baseline: 771.5 nonfatal injuries per 100,000 population were caused by motor vehicle crashes in 2008, Target: 694.4 nonfatal injuries per 100,000 population)

DATA SOURCES and

DATA ISSUES

Numerator: State E-coded hospital discharge data.

Denominator: Census Bureau data, State population estimates.

Potential Data Source: National Hospital Discharge Survey (NHDS), Centers for Disease Control and Prevention, NCHS.

SIGNIFICANCE

Among U.S. children, injury remains the leading cause of morbidity and mortality. It is estimated that 9.2 million children, because of unintentional injuries, have an initial emergency department visit each year. Motor vehicle crashes remain the leading cause of death among 5-14 year olds in the U.S. and the second leading cause of injury death among 1-4 year olds. Annually the economic loss from motor vehicle crashes due to medical costs and loss of productivity exceed $99 billion dollars. (Centers for Disease Control and Prevention: Childhood Injury Report, 2000-2006)

04C

HEALTH STATUS INDICATOR

The rate per 100,000 of nonfatal injuries due to motor vehicle crashes among youth aged 15 through 24 years.

GOAL

To reduce the number of hospitalizations among youth aged 15 through 24 years due to motor vehicle crashes.

DEFINITION

Numerator: Number of youths aged 15 through 24 years with a hospital discharge for nonfatal injuries due to motor vehicle crashes in the reporting year.

Denominator: Number of youths aged 15 through 24 years in the State for the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2020

OBJECTIVE

DATA SOURCES and

DATA ISSUES

Numerator: State E-coded hospital discharge data.

Denominator: Census Bureau data, State population estimates.

SIGNIFICANCE

Among U.S. children, injury remains the leading cause of morbidity and mortality. It is estimated that 9.2 million children, because of unintentional injuries, have an initial emergency department visit each year. Motor vehicle crashes remain the leading cause of death among 5-34 year olds in the U.S. and annually the economic loss from motor vehicle crashes due to medical costs and loss of productivity exceed $99 billion dollars. (Centers for Disease Control and Prevention: Childhood Injury Report, 2000-2006)

05A

HEALTH STATUS INDICATOR

The rate per 1,000 women aged 15 through 19 years with a reported case of chlamydia.

GOAL

To decrease the sexually transmitted disease (chlamydia) rates among women aged 15 through 19 years.

DEFINITION

Numerator: Number of women aged 15 through 19 years with a reported case of chlamydia.

Denominator: Number of women aged 15 through 19 years in the State in the reporting year.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Sexually Transmitted Diseases (STD) Objective 1: Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections.

Related to Objective STD-2: (Developmental) Reduce chlamydia rates among females aged 15 to 44 years.

DATA SOURCES and

DATA ISSUES

State STD Program Surveillance, State Communicable Disease Registry.

SIGNIFICANCE

Rates of chlamydia are highest among adolescents and young adults. In 2008, 3,275.8 cases of chlamydia were reported per 100,000 females aged 15-19 years, compared to 30.9 cases per 100,000 women aged 45-54 years. (Women’s Health USA 2010 Report, Department of Health and Human Services, Health Resources and Services Administration)

05B

HEALTH STATUS INDICATOR

The rate per 1,000 women aged 20 through 44 years with a reported case of chlamydia.

GOAL

To decrease the sexually transmitted disease (chlamydia) rates among women aged 20 through 44 years.

DEFINITION

Numerator: Number of women aged 20 through 44 years with a reported case of chlamydia.

Denominator: Number of women aged 20 through 44 years in the State in the reporting year.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Sexually Transmitted Diseases (STD) Objective 2: (Developmental) Reduce chlamydia rates among females aged 15 to 44 years.

DATA SOURCES and

DATA ISSUES

State STD Program Surveillance, State Communicable Disease Registry.

SIGNIFICANCE

Rates of chlamydia are highest among adolescents and young adults. In 2008, 3,179.9 cases of chlamydia were reported per 100,000 females aged 20-24 years and 1,240.6 cases per 100,000 females aged 25-29 years, compared to 30.9 cases per 100,000 women aged 45-54 years. (Women’s Health USA 2010 Report, Department of Health and Human Services, Health Resources and Services Administration)

06 A & B

HEALTH STATUS INDICATOR

Infants and children aged 0 through 24 years enumerated by age subgroup, race, and ethnicity.

GOAL

To enumerate the total population of children aged 0 through 24 years by age subgroup, race, and ethnicity.

DEFINITION

Tables 06 A & B on Health Status Indicator Form 21 have cells for populations of subgroups of children aged 0 through 24 years aggregated by race and ethnicity. In each cell of the two tables, enumerate the population figures requested.

Unit: Count of State residents aged 0 through 24 years old.

Text: Number

HEALTHY PEOPLE 2020

OBJECTIVE

No specific Healthy People 2020 Objective.

DATA SOURCES and

DATA ISSUES

Census Bureau data, State projections, Vital Records and Health Statistics.

SIGNIFICANCE

The racial and ethnic composition of the U.S. child population has changed dramatically, reflective of the increasing diversity of the population as a whole. In 2008, Hispanic children represented 22% of the child population, Black children 15%, Asian/Pacific Islander children 4.4%, and white children 56.2%. Maternal and Child Health (MCH) professionals and policy makers must develop strategies and programs to address the needs of these growing segments of the population. Data reveals marked variations in morbidity and mortality by race and/or ethnicity. Reaching the goal of eliminating racial and ethnic disparities in health outcomes will necessitate identifying barriers to accessing family-centered, community-oriented, culturally-competent, and comprehensive care for all Americans. Improved collection and use of standardized demographic data will identify high-risk populations and monitor the effectiveness of health promotion and disease prevention interventions targeting these groups.

07 A & B

HEALTH STATUS INDICATOR

Live births to women (of all ages) enumerated by maternal age, race, and ethnicity.

GOAL

To enumerate total live births by maternal age, race, and ethnicity.

DEFINITION

Tables 07 A & B on Health Status Indicator Form 21 have cells for population subgroups of women aggregated by race and ethnicity. In each cell on the two tables, enumerate the live births to the groups of women indicated.

Units: Count of State live births. Text: Number

HEALTHY PEOPLE 2020

OBJECTIVE

No specific Healthy People 2020 objective.

DATA SOURCES and

DATA ISSUES

Vital Records.

SIGNIFICANCE

Younger or older mothers, and mothers belonging to racial and/or ethnic minority groups may be at increased risk of adverse maternal outcomes. Identifying populations of women and their infants at risk, and implementing coordinated systems of pre-conceptual/perinatal services that assures receipt of risk-appropriate health care delivery is essential for healthy mothers and babies.

08 A & B

HEALTH STATUS INDICATOR

Deaths of infants and children aged 0 through 24 years enumerated by age subgroup, race, and ethnicity.

GOAL

To enumerate deaths of infants and children aged 0 through 24 years by age subgroup, race, and ethnicity.

DEFINITION

Tables 08 A & B on Health Status Indicator Form 21 have cells for population subgroups of children aged birth through 24 years, aggregated by race and ethnicity. In each cell on the two tables, enumerate the deaths in each sub-population.

Units: Count of State residents aged 0 through 24 years.

Text: Number

HEALTHY PEOPLE 2020

OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 1: Reduce the rate of fetal and infant deaths.

Related to Objective MICH-3: Reduce the rate of child deaths.

Related to Objective MICH-4: Reduce the rate of adolescent and young adult deaths.

DATA SOURCES and

DATA ISSUES

Vital Records.

SIGNIFICANCE

The greatest racial and ethnic disparities are seen in the following causes of death in infants: disorders relating to pre-term birth and unspecified low birth weight; respiratory distress syndrome; infections specific to the perinatal period; complications of pregnancy; and sudden infant death syndrome (SIDS). In some American Indian/Alaskan Native populations, the incidence of SIDS is three times that of white populations. African American adolescent males have the highest homicide rates in the country. Suicide among adolescent males in certain American Indian/Alaskan Native tribes has reached epidemic proportions. Identifying at-risk populations and implementing and monitoring prevention/intervention programs will play an integral role in eliminating disparities in mortality.

09 A & B

HEALTH STATUS INDICATOR

Infants and children aged 0 through 19 years in miscellaneous situations or enrolled in various State programs enumerated by race and ethnicity.

GOAL

To determine number/percentage of infants and children aged 0 through 19 years in miscellaneous situations or enrolled in various State programs.

DEFINITION

Tables 09 A & B on Health Status Indicator Form 21 have cells for populations of subgroups of infants and children aged 0 through 19 years in miscellaneous situations and/or State programs by race and ethnicity. Complete each of the cells in the tables with a percentage or count as appropriate.

Units: 100 or count Text: Percent, number or rate

HEALTHY PEOPLE 2020

OBJECTIVE

No specific Healthy People 2020 objective.

DATA SOURCES and

DATA ISSUES

TANF, Medicaid, CHIP, SNAP, and WIC files; State juvenile criminal justice and Board of Education files; linked child health data files; Census Bureau data.

SIGNIFICANCE

Adverse health outcomes disproportionately affect infants and children in foster care, and single parent families are particularly vulnerable to poverty (with 43.4% of children living in female-headed households experiencing poverty in 2008). In 2008, 19% of all children in the U.S., more than 14 million children under 18 years, lived in households below the federal poverty level. Significant ethnic and racial disparities exist in poverty status, with 34.7% of Black and 30.6% of Hispanic children living in households below the federal poverty level, compared to 10.6% of non-Hispanic White children. (Child Health USA 2010 Report: Department of Health and Human Services, Health Resources and Services Administration)

Leaving high school early before graduation can lead to continued poverty and a higher incidence of juvenile arrests. A number of federal and State programs work to protect the health and well being of children and their families living in poverty. Yet, many infants and children eligible for programs such as Medicaid, CHIP and other State programs are not enrolled. Data linkage of State program files with Medicaid may identify factors associated with program eligibility without full participation.

HEALTH STATUS INDICATOR

Geographic living area for all resident children aged 0 through 19 years.

GOAL

To determine the number of children in the State aged 0 through 19 years by geographic living area.

DEFINITION

Table 10 on Health Status Indicator Form 21 includes cells for children in sub-population groups ranging from birth through 19 years of age. Complete the cells with the number of children in those age ranges living in metropolitan, urban, rural, or frontier geographic areas.

Units: Count Text: Number

HEALTHY PEOPLE 2020

OBJECTIVE

No specific Healthy People 2020 objective.

DATA SOURCES and

DATA ISSUES

Census Bureau data or State population projections.

SIGNIFICANCE

Child health outcomes and the patterns of utilization of health care services can differ greatly by geographic area. Poor families living in metropolitan and urban areas without a regular source of coordinated health services may over-utilize emergency services or present as frequent walk-ins to community or public health clinics. Access to care for the poor and underserved in rural and frontier areas is largely dependent on the number of providers available and willing to see the uninsured or accept Medicaid or CHIP. Barriers to quality health care may also include inadequate transport to care and ill-equipped health care facilities.

HEALTH STATUS INDICATOR

Poverty levels for the total State population.

GOAL

To determine the percentage of the State population at 50 percent, 100 percent, and 200 percent of the federal poverty level.

DEFINITION

Table 11 on Health Status Indicator Form 21 has cells for the population at various poverty levels. Please complete the cells with the count of total population and the percentages of the population living at the 50 percent, 100 percent or 200 percent poverty level.

Units: Count for population and 100.

Text: Number for population and percent.

HEALTHY PEOPLE 2020

OBJECTIVE

No specific Healthy People 2020 Objective.

DATA SOURCES and

DATA ISSUES

Census Bureau data or State population projections.

SIGNIFICANCE

Eligibility for Medicaid, CHIP and other State programs is in part determined by family income as a percentage of federally defined poverty levels. States have some discretion in determining which groups their Medicaid and CHIP programs will cover and the financial criteria for Medicaid and CHIP eligibility.

HEALTH STATUS INDICATOR

Poverty levels for all children aged 0 through 19 years.

GOAL

To determine the percentage of all children aged 0 through 19 years at 50 percent, 100 percent, and 200 percent of the federal poverty level.

DEFINITION

Table 12 on Health Status Indicator Form 21 has cells for the State population aged 0 through 19 years and percentages of that population at various poverty levels. Please complete the cells with the count of the population in that age range and the percentages of that population living at the 50 percent, 100 percent or 200 percent poverty level.

Units: Count for population and 100.

Text: Number for population and percent.

HEALTHY PEOPLE 2020

OBJECTIVE

No specific Healthy People 2020 Objective.

DATA SOURCES and

DATA ISSUES

U.S. Census Bureau’s American Community Survey.

SIGNIFICANCE

VIII – GLOSSARY

Adequate prenatal care - Prenatal care where the observed to expected prenatal visits is greater than or equal to 80% (the Kotelchuck Index).

Administration of Title V Funds - The amount of funds the State uses for the management of the Title V allocation. It is limited by statute to 10 percent of the Federal Title V allotment.

Assessment – (see “Needs Assessment”).

BRFSS - The Behavioral Risk Factor Surveillance System (BRFSS) is the world’s largest, on-going telephone health survey system, tracking health conditions and risk behaviors in the United States yearly since 1984. Currently, data are collected monthly in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. http://www.cdc.gov/brfss/

Capacity - Program capacity includes delivery systems, workforce, policies, and support systems (e.g., training, research, technical assistance, and information systems) and other infrastructure needed to maintain service delivery and policy making activities. Program capacity results measure the strength of the human and material resources necessary to meet public health obligations. As program capacity sets the stage for other activities, program capacity results are closely related to the results for process, health outcome, and risk factors. Program capacity results should answer the question, “What does the State need to achieve the results we want?”

Care Coordination Services for Children With Special Health Care Needs (CSHCN, see definition below) - those services that promote the effective and efficient organization and utilization of resources to assure access to necessary comprehensive services for children with special health care needs and their families. [Title V Sec. 501(b)(3)]

Carryover (as used in Forms 2 and 3) - The unobligated balance from the previous years MCH Block Grant Federal Allocation.

Case Management Services - For pregnant women - those services that assure access to quality prenatal, delivery and postpartum care. For infants up to age one - those services that assure access to quality preventive and primary care services. (Title V Sec. 501(b)(4)

Children - A child from 1st birthday through the 21st year, who is not otherwise included in any other class of individuals.

Children With Special Health Care Needs (CSHCN) - (For budgetary purposes) Infants or children from birth through the 21st year with special health care needs who the State has elected to provide with services funded through Title V. CSHCN are children who have health problems requiring more than routine and basic care including children with or at risk of disabilities, chronic illnesses and conditions and health-related education and behavioral problems. (For planning and systems development) - Those children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

Children With Special Health Care Needs (CSHCN) - Constructs of a Service System

State Program Collaboration with Other State Agencies and Private Organizations

States establish and maintain ongoing interagency collaborative processes for the assessment of needs with respect to the development of community-based systems of services for CSHCN. State programs collaborate with other agencies and organizations in the formulation of coordinated policies, standards, data collection and analysis, financing of services, and program monitoring to assure comprehensive, coordinated services for CSHCN and their families.

State Support for Communities

State programs emphasize the development of community-based programs by establishing and maintaining a process for facilitating community systems building through mechanisms such as technical assistance and consultation, education and training, common data protocols, and financial resources for communities engaged in systems development to assure that the unique needs of CSHCN are met.

Coordination of Health Components of Community-Based Systems

A mechanism exists in communities across the State for coordination of health services with one another. This includes coordination among providers of primary care, habilitative and rehabilitative services, other specialty medical treatment services, mental health services, and home health care.

4. Coordination of Health Services with Other Services at the Community Level

A mechanism exists in communities across the State for coordination and service integration among programs serving CSHCN, including early intervention and special education, social services, and family support services.

Community - a group of individuals living as a smaller social unit within the confines of a larger one due to common geographic boundaries, cultural identity, a common work environment, common interests, etc.

Community-based Care - services provided within the context of a defined community.

Community-based Service System - an organized network of services that are grounded in a plan developed by a community and that is based upon Needs Assessments.

Coordination - (see Care Coordination Services).

Cultural Competence – a set of values, behaviors, attitudes, and practices within a system, organization, program, or among individuals and which enables them to work effectively cross culturally. Further, it refers to the ability to honor and respect the beliefs, language, inter-personal styles and behaviors of individuals and families receiving services, as well as staff who are providing such services. At a systems, organizational, or program level, cultural competence requires a comprehensive and coordinated plan that includes interventions at all the levels from policy-making to the individual, and is a dynamic, ongoing, process that requires a long-term commitment. A component of cultural competence is linguistic competence, the capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who are not literate or have low literacy skills, and individuals with disabilities.

Regarding the principles of cultural competence, an organization should value diversity in families, staff, providers and communities; have the capacity for cultural self-assessment; be conscious of the dynamics inherent when cultures interact, e.g. families and providers; institutionalize cultural knowledge; and develop adaptations to service delivery and partnership building reflecting an understanding of cultural diversity. An individual should examine one’s own attitude and values; acquire the values, knowledge, and skills for working in cross cultural situations; and remember that everyone has a culture.

Sources: Maternal and Child Health Bureau (MCHB), Guidance and Performance Measures for Discretionary Grants, Health Resources and Services Administration, U.S. Department of Health and Human Services, Denboba and Goode, 1999 and 2004.

Cross, Bazron, Dennis and Isaacs, Towards a Culturally Competent System of Care, 1989.

Goode and Jones, Definition of Linguistic Competence, National Center for Cultural Competence, Revised 2004.

Denboba, “Federal Viewpoint,” Special Additions Newsletter for Children with Special Health Care Needs, Spring/Summer 2005.

Culturally Sensitive - the recognition and understanding that different cultures may have different concepts and practices with regard to health care; the respect of those differences and the development of approaches to health care with those differences in mind.

Data Systems Development – Development of data management systems (electronic or other) or linking of existing databases to support States’ ability to collect, tabulate, analyze, and report data accurately. (also see Systems Development)

Deliveries - women who received a medical care procedure (were provided prenatal, delivery or postpartum care) associated with the delivery or expulsion of a live birth or fetal death.

Direct Services/Direct Health Care Services - those services generally delivered one-on-one between a health professional and a patient in an office, clinic or emergency room which may include primary care physicians, registered dietitians, public health or visiting nurses, nurses certified for obstetric and pediatric primary care, medical social workers, nutritionists, dentists, sub-specialty physicians who serve children with special health care needs, audiologists, occupational therapists, physical therapists, speech and language therapists, specialty registered dietitians. Basic services include what most consider ordinary medical care, inpatient and outpatient medical services, allied health services, drugs, laboratory testing, x-ray services, dental care, and pharmaceutical products and services. State Title V programs support - by directly operating programs or by funding local providers - services such as prenatal care, child health including immunizations and treatment or referrals, school health and family planning. For CSHCN, these services include specialty and sub-specialty care for those with HIV/AIDS, hemophilia, birth defects, chronic illness, and other conditions requiring sophisticated technology, access to highly trained specialists, or an array of services not generally available in most communities.

Early Neonatal – Infants less than or equal to 6 days of age.

Enabling Services - Services that allow or provide for access to and the derivation of benefits from, the array of basic health care services and include such things as transportation, translation services, outreach, respite care, health education, family support services, purchase of health insurance, case management, coordination of with Medicaid, WIC and education. These services are especially required for the low income, disadvantaged, geographically or culturally isolated, and those with special and complicated health needs. For many of these individuals, the enabling services are essential - for without them access is not possible. Enabling services most commonly provided by agencies for CSHCN include transportation, care coordination, translation services, home visiting, and family outreach. Family support activities include parent support groups, family training workshops, advocacy, nutrition and social work.

EPSDT - Early and Periodic Screening, Diagnosis and Treatment - a program for medical assistance recipients under the age of 21, including those who are parents. The program has a Medical Protocol and Periodicity Schedule for well-child screening that provides for regular health check-ups, vision/hearing/dental screenings, immunizations and treatment for health problems.

Family-Centered Care – Approach that assures the health and well-being of children and their families through a respectful family-professional partnership. It honors the strengths, cultures, traditions and expertise that everyone brings to this relationship. Family-centered care is the standard of practice which results in high quality services.

Family/Professional Partnerships – The foundation of family-centered care is the partnership between families and professionals. The following key principles to this partnership are:

Families and professionals work together in the best interest of the child and the family. As the child grows, s/he assumes a partnership role;
Everyone respects the skills and expertise brought to the relationship;
Trust is acknowledged as fundamental;
Communication and information sharing are open and objective;
Participants make decisions together; and
There is a willingness to negotiate.

Based on this partnership, family-centered care:

Acknowledges the family as the constant in a child’s life;
Builds on family strengths;
Supports the child in learning about and participating in his/her care and decision-making;
Honors cultural diversity and family traditions;
Recognizes the importance of community-based services;
Promotes an individual and developmental approach;
Encourages family-to-family and peer support;
Supports youth as they transition to adulthood;
Develops policies, practices, and systems that are family-friendly and family-centered in all settings; and
Celebrates successes.

Sources: National Center for Family-Centered Care. Family-Centered Care for Children with Special Health Care Needs. (1989). Bethesda, MD: Association for the Care of Children’s Health.

Bishop, Woll and Arango (1993). Family/Professional Collaboration for Children with Special Health Care Needs and their Families. Burlington, VT: University of Vermont, Department of Social Work.

Family-Centered Care Projects 1 and 2 (2002-2004). Bishop, Woll, Arango. Algodones, NM; Algodones Associates.

Federal (Allocation) - (as it applies specifically to the Application Face Sheet [SF 424] and Forms 2 and 3) The funding provided to the States under the Federal Title V Block Grant in any given year.

Government Performance and Results Act (GPRA) - Federal legislation enacted in 1993 that requires Federal agencies to develop strategic plans, prepare annual plans setting performance goals, and report annually on actual performance.

Health Care System - the entirety of the agencies, services, and providers involved or potentially involved in the health care of community members and the interactions among those agencies, services and providers.

Infants - Children less than one year of age not included in any other class of individuals.

Infrastructure Building Services - The services that are the base of the MCH pyramid of health services and form its foundation are activities directed at improving and maintaining the health status of all women and children by providing support for development and maintenance of comprehensive health services systems including development and maintenance of health services standards/guidelines, training, data and planning systems. Examples include Needs Assessment, evaluation, planning, policy development, coordination, quality assurance, standards development, monitoring, training, applied research, information systems and systems of care. In the development of systems of care it should be assured that the systems are family centered, community based and culturally competent.

Jurisdictions - In the Maternal and Child Health Block Grant Program, the following are called jurisdictions: the District of Columbia, the Republic of the Marshall Islands, the Federated States of Micronesia, the Republic of Palau and the following U.S. territories - the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.

Kotelchuck Index - An indicator of the adequacy of prenatal care. The two-part (Kotelchuck) Adequacy of Prenatal Care Utilization Index combines independent assessment of the timing of prenatal care initiation and the frequency of visits received after initiation. See Adequate Prenatal Care.

Local (as used in Forms 2 and 3 under “Estimated Funding”) - Funds derived from local jurisdictions within the State that are used for MCH program activities.

Low Income - an individual or family with an income determined to be below the income official poverty line defined by the Office of Management and Budget and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981. [Title V, Sec. 501 (b)(2)]

MCH Pyramid of Health Services - (see “Types of Services”).

Measures - (see “Performance Measures”).

Morbidity – A general term for any health condition that encompasses diseases, injuries, and impairments in a population or group.

Mortality – A general term for the incidence of deaths in a population or group. The number of deaths by age, sex, race/ethnicity, geographic area, and cause of death.

Mortality rate – The number of deaths occurring in a given population at risk during a specific time period. The number of deaths in a demographic group (numerator) divided by the population (denominator) and expressed as per 1000 live births (infant mortality rate only) or per 100,000 population, generally at mid-year.

National Children with Special Health Care Needs (CSHCN) Survey – National survey conducted every four years which serves as the primary data source for reporting on National Performance Measures 2-6.

National Survey of Children’s Health – National survey conducted every four years which provides a snapshot of the status of children’s health in each State and in the Nation.

Needs Assessment – a process to understand the strengths and needs of the health service system within a community or population. For maternal and child health purposes, needs assessment efforts consider the following components: 1) health status, 2) health service utilization, 3) health systems capacity, and 4) population/community characteristics and contextual characteristics.

Neonatal - The neonatal period begins at birth and lasts through the 28th day following birth.

Newborn – a human infant from the time of birth through the 28th day of life.

Objectives - The yardsticks by which an agency can measure its efforts to accomplish a goal. (See also “Performance Objectives”)

Other Federal Funds (Forms 2 and 3) - Federal funds other than the Title V Block Grant that are under the control of the person responsible for administration of the Title V program. These may include, but are not limited to: WIC, EMSC, Healthy Start, SPRANS, HIV/AIDs monies, CISS funds, MCH targeted funds from CDC, and MCH Education funds.

Others (as in Forms 4, 7, and 10) - Women of childbearing age, over age 21, and any others defined by the State and not otherwise included in any of the other listed classes of individuals.

Outcome Objectives - Objectives that describe the eventual result sought, the target date, the target population, and the desired level of achievement for the result. Outcome objectives are related to health outcome and are usually expressed in terms of morbidity and mortality.

Outcome Measure - The ultimate focus and desired result of any set of public health program activities and interventions is an improved health outcome. Morbidity and mortality statistics are indicators of achievement of health outcomes. Health outcome results are usually longer term and tied to the ultimate program goal.

Performance Indicator - The statistical or quantitative value that expresses the result of a performance objective.

Performance Measure - a narrative statement that describes a specific maternal and child health need or requirement that, when successfully addressed, will lead to or will assist in leading to a specific health outcome within a community or jurisdiction and generally within a specified time frame. (Example: “The rate of women in [State] who receive early prenatal care in 20__.” This performance measure will assist in leading to [the health outcome measure of] reducing the rate of infant mortality in the State).

Performance Measurement - The collection of data on, recording of, or tabulation of results or achievements, usually for comparison to a benchmark.

Performance Objectives - A statement of intention with which actual achievement and results can be measured and compared. Performance objective statements clearly describe what is to be achieved, when it is to be achieved, the extent of the achievement, and the target populations.

Perinatal – Period from gestation of 28 weeks or more to 7 days or less after birth.

Population Based Services - Preventive interventions and personal health services, developed and available for the entire MCH population of the State rather than for individuals in a one-on-one situation. Disease prevention, health promotion, and statewide outreach are major components. Common among these services are newborn screening, lead screening, immunization, Sudden Infant Death Syndrome counseling, oral health, injury prevention, nutrition and outreach/public education. These services are generally available whether the mother or child receives care in the private or public system, in a rural clinic or an HMO, and whether insured or not.

Post-neonatal - of, relating to, or affecting the infant and especially the human infant usually from the end of the first month to a year after birth.

PRAMS - Pregnancy Risk Assessment Monitoring System - a surveillance project of the Centers for Disease Control and Prevention (CDC) and State health departments to collect State- specific, population-based data on maternal attitudes and experiences prior to, during, and immediately following pregnancy.

Pregnant Woman - A female from the time that she conceives to 60 days after birth, delivery, or expulsion of fetus.

Prenatal - Occurring or existing before birth, referring to both the care of the woman during pregnancy and the growth and development of the fetus.

Preventive Services - activities aimed at reducing the incidence of health problems or disease prevalence in the community, or the personal risk factors for such diseases or conditions.

Primary Care/Primary Care Services - the provision of comprehensive personal health services that include health maintenance and preventive services, initial assessment of health problems, treatment of uncomplicated and diagnosed chronic health problems, and the overall management of an individual’s or family’s health care services.

Process - Process results are indicators of activities, methods, and interventions that support the achievement of outcomes (e.g., improved health status or reduction in risk factors). A focus on process results can lead to an understanding of how practices and procedures can be improved to reach successful outcomes. Process results are a mechanism for review and accountability, and as such, tend to be shorter term than results focused on health outcomes or risk factors. The utility of process results often depends on the strength of the relationship between the process and the outcome. Process results should answer the question, “Why should this process be undertaken and measured (i.e., what is its relationship to achievement of a health outcome or risk factor result)?”

Process Objectives - The objectives for activities and interventions that drive the achievement of higher-level objectives.

Program Income (as used in the Application Face Sheet [SF 424] and Forms 2 and 3) - Funds collected by State MCH agencies from sources generated by the State’s MCH program to include insurance payments, Medicaid reimbursements, HMO payments, etc.

Risk Factor Objectives - Objectives that describe an improvement in risk factors (usually behavioral or physiological) that cause morbidity and mortality.

Risk Factors - Public health activities and programs that focus on reduction of scientifically established direct causes of, and contributors to, morbidity and mortality (i.e., risk factors) are essential steps toward achieving health outcomes. Changes in behavior or physiological conditions are the indicators of achievement of risk factor results. Results focused on risk factors tend to be intermediate term. Risk factor results should answer the question, “Why should the State address this risk factor (i.e., what health outcome will this result support)?”

State - as used in this guidance, includes the 50 States and the 9 jurisdictions. (See also “Jurisdictions”)

State Funds (as used in Forms 2 and 3) - The State’s required matching funds (including overmatch) in any given year.

SUID/SIDS –

Sudden Unexpected Infant Deaths (SUID) - Sudden Unexpected Infant Deaths are defined as deaths in infants less than 1 year of age that occur suddenly and unexpectedly, and whose cause of death are not immediately obvious prior to investigation.

Sudden Infant Death Syndrome (SIDS) is defined as the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history.

Systems Development - activities involving the creation or enhancement of organizational infrastructures at the community level for the delivery of health services and other needed ancillary services to individuals in the community by improving the service capacity of health care service providers.

Targets - An aspired outcome that is explicitly stated, e.g. achieve 90% of timeliness of reporting, 100% completeness of reporting, etc. In this guidance, “Targets” is often used interchangeably with “Objectives.”

Technical Assistance (TA) - The process of providing advice, assistance, and training by an expert with specific technical/content knowledge to address an identified need. Technical Assistance relationships are program-focused, and may use an interactive, on-site/hands-on approach as well as telephone or email assistance. Technical Assistance delivery is short in duration, customized to meet the needs of the client, and offers prescriptive solutions to a specific issue. [Concordia University, 2007. www.mnsmart.org]

Title V – The authorizing legislation for the Maternal and Child Health Services Block Grant to States Program, which is found in Title V of the Social Security Act.

Title V, number of deliveries to pregnant women served under (as used in Form 8) - Unduplicated number of deliveries to pregnant women who were provided prenatal, delivery, or post-partum services through the Title V program during the reporting period.

Title V, number of infants enrolled under - The unduplicated count of infants provided a direct service by the State’s Title V program during the reporting period.

Title XIX – The authorizing legislation for the Medicaid program, which is found in Title XIX of the Social Security Act.

Title XIX, number of infants entitled to - The unduplicated count of infants who were eligible for the State’s Title XIX (Medicaid) program at any time during the reporting period.

Title XIX, number of pregnant women entitled to - The number of pregnant women who delivered during the reporting period who were eligible for the State’s Title XIX (Medicaid) program.

Title XXI - Children's Health Insurance Program (CHIP) financed via CMS through FY 2013. The purpose of this title is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children. Sec. 2101. [42 U.S.C. 1397aa]

Total MCH Funding - All the MCH funds administered by a State MCH program which is made up of the sum of the Federal Title V Block grant allocation, the Applicant’s funds (carryover from the previous year’s MCH Block Grant allocation - the unobligated balance), the State funds (the total matching funds for the Title V allocation - match and overmatch), Local funds (total of MCH dedicated funds from local government within the state), Other federal funds (monies other than the Title V Block Grant that are under the control of the person responsible for administration of the Title V program), and Program Income (those collected by State MCH agencies from insurance payments, Medicaid, HMO’s, etc.)

Types of Services - The major kinds or levels of health care services covered under Title V activities. See individual definitions under “Infrastructure Building,” “Population Based Services,” “Enabling Services” and “Direct Services.”

YRBS - Youth Risk Behavior Survey - A National school-based survey conducted annually by CDC and State health departments to assess the prevalence of health risk behaviors among high school students.

YRBSS - Youth Risk Behavior Surveillance System - The YRBSS monitors six types of health-risk behaviors that contribute to the leading causes of death and disability among youth and adults. YRBSS includes a national school-based survey conducted by CDC and state, territorial, tribal, and local surveys conducted by state, territorial, and local education and health agencies and tribal governments.

The YRBSS includes:

Behaviors that contribute to unintentional injuries and violence
Tobacco use
Alcohol and other drug use
Sexual risk behaviors
Unhealthy dietary behaviors
Physical inactivity

YRBSS also measures the prevalence of obesity and asthma among youth and young adults.

IX - TECHNICAL NOTE:

GUIDELINES FOR CALCULATING PERFORMANCE

MEASURES USING SMALL SAMPLES *

The procedures outlined below are intended to assist States in displaying data on required Title V Performance Measures. When the number of events in any one year is very small, other approaches are needed to compare results and determining statistical significance. The following guidelines are intended to provide a consistent approach for those States confronting “the small numbers” situation.

GUIDELINES

Number of Events	Calculate Rate?	Calculate Confidence Interval?	Suggested Approach
A. If at least 20 events (numerator)	Yes	Yes	Use calculated rate
B. If fewer than 20 events (numerator)	Yes	Yes	First, calculate a three year average rate, then calculate a confidence interval
C. If 3 year average is fewer than 20 events but greater than 4 events (numerator)	Yes	Yes	Calculate a standardized ratio
D. If fewer than 5 events (numerator)	No	No	Use the low number checkbox provided in the Title V Information System and include a note that further explains the data.
E. Special Case: Infant and Fetal Mortality: If fewer than 1000 live births (denominator)	No	No	Apply above alternatives and consider using a standardized mortality ratio
F. Special Case: Childhood Mortality: If fewer than 5 events (numerator)	No	No	Apply above alternatives and consider using a standardized mortality ratio

*Source: Family Health Outcomes Project

PROCEDURES

Calculate rates (at least 20 events)

Example #1: 25 infant deaths and 860 live births

calculate rate:

25 infant deaths

860 live births

X 1,000 = 29.1 (rate)

calculate 95% confidence interval:

_______________

= rate  1.96 X √ rate/denominator X 1,000

________

= 29.1  1.96 X √ .029/860 X 1,000

= 29.1  1.96 X 5.82 = 29.1  11.4

= (17.7, 40.5)

Calculate 3 year annual average rates (fewer than 20 events)

To calculate the numerator:

Add up the number of events for the current year and the number of events for the previous 2 years.

To calculate the denominator:

Method 1: Add the population denominator for the current year combined with the population denominators for the previous 2 years.

Method 2: Use the population statistic for the middle year only.

For a three year average rate, divide the numerator by the denominator and multiply by 1,000 for a rate per 1,000. Calculate XYZ State’s average annual death rate per 1,000 for 1989-1991 as follows:

Method 1:

(D1 + D2 + D3)

X 1,000 = Three Year Average Rate

Method 2:

1/3 X (D1 + D2 + D3)

X 1,000 = Three Year Average Rate

Where:

D = the number of deaths in years 1, 2, and 3, respectively

P = the total population in years 1, 2, and 3, respectively

Example #2: 5 infant deaths in 1989, 6 in 1990, 7 in 1991; and 1,520 live births in 1989, 1,530 in 1990, and 1,525 in 1991

Calculate three year average using method 1:

(5 + 6 + 7)

(1,520 + 1,530 + 1,525)

X 1,000 = 3.93

Calculate three year average using method 2:

1/3 X (5 + 6 + 7)

1,530

X 1,000 = 3.92

Note: The actual number of events for each year should be documented along with the three year total and the calculated annual average rate.

Calculate a Standardized Ratio

A standardized ratio is the relationship between the observed number of events versus the expected number of events.

To calculate the expected number of events, National rates are applied to the State denominator to generate an expected number of events if the State was the same as the National rate.

State Denominator X U.S. Rate

1,000

= Expected Number of Events

Example 3: In 1993, the National infant mortality rate was 6.8 per 1,000 and XYZ State had 500 births.

calculate standardized ratio:

Calculate the expected number of infant deaths by multiplying 500 by 6.8 and dividing by 1,000 (even though, the actual observed number of deaths was 6):

500 X 6.8

1,000

= Expected Number of Events

Dividing the observed number of events by the expected number and multiplying by 100:

Observed Number of Events

Expected Number of Events

X 100 = Standardized Ratio

_6_

3.3

X 100 = 181.8

If the Standardized Ratio is:

It means that the State rate is:

Less than 100

Equal to 100

Greater than 100 but ≤ 200

Greater than 200

Lower than the U.S. rate

Same as the U.S. rate

Higher than the U.S. rate

Significantly higher than the U.S. rate

When the standardized ration is greater than 100, further investigation by the State or Territory MCH office may be indicated. Follow-up analysis can be conducted by examining the characteristics of individual cases, or by performing case studies.

X – STATE SUPPORTING DOCUMENTS

Organizational Charts

Other State supporting documents

0 Timely is defined by each State based on established National guidelines for the individual conditions.

Body Mass Index is defined as the ratio of weight in kilograms to the square of the height in meters.

0 Childhood obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex, based on the reference values included in the National Center for Health Statistics 2000 growth charts. Childhood overweight is defined as a BMI between the 85th and 95th percentiles.

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Form 1 MCHB Block Grant Guidance for Application/Annual Report

Maternal and Child Health Services Block Grant Report

FINAL Application_Report AttachCGuidance_10-31-11 (2)

Maternal and Child Health Services Block Grant Report

OMB: 0915-0172

APPLICATION FOR

FEDERAL ASSISTANCE OMB Approval No. 0348-0043

Applicant Identifier

Application

Pre-application

State Application Identifier

FEDERAL IDENTIFIER

INSTRUCTIONS FOR COMPLETION OF FORM 2

MCH BUDGET DETAILS FOR FY ____

FORM 3

INSTRUCTIONS FOR THE COMPLETION OF FORM 3

STATE MCH FUNDING PROFILE

PERFORMANCE MEASURE

I. GENERAL SYSTEMS CAPACITY ISSUES

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING AND TRACKING FORM – HSCI 09A & 09B

DATABASES OR SURVEYS

ANNUAL DATA LINKAGES

Annual linkage of birth certificates and Medicaid eligibility or paid claims files.

REGISTRIES AND SURVEYS

FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING AND TRACKING FORM – HSCI 09A & 09B

(Continuation Page)

INSTRUCTIONS FOR COMPLETION FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING AND TRACKING FORM – HSCI 09A & 09B

FORM 20

HEALTH STATUS INDICATORS

IX - TECHNICAL NOTE:

GUIDELINES FOR CALCULATING PERFORMANCE

MEASURES USING SMALL SAMPLES *

PROCEDURES