Home Visitor Logs

OMB Control No: 0970-0402

Expiration Date: 7/31/2015

Length of time for instrument: 0.20 hours

ATTACHMENT 20: MIHOPE HOME VISITOR LOG

8/1311/20/2012

HOME VISITOR LOG

The U.S. Department of Health and Human Services has contracted with MDRC to evaluate the federal Maternal, Infant and Early Childhood Home Visiting program (MIECHV).

The Mother and Infant Home Visiting Program Evaluation (MIHOPE) is designed to build knowledge for policymakers and practitioners about the effectiveness of MIECHV.

Your answers will be kept confidential. Only the research team will have access to this information. Your answers will not be shared with anyone at your program or any other agencies. In our research reports, the information you provide will not be attributed by name to you or your individual program.

Please complete a log for each study participant on your caseload (until the case is closed) that is participating in the MIHOPE study. After you complete a log for one client, you will have the opportunity to complete the same set of questions for any additional clients. At the end of every month, you will also be prompted to answer a few questions about training you have received during the past month.

If you spent time with a participating family during the past week, the log should take approximately five minutes to complete.

Home Visitor Web-based Log Home Page

Options:

1. Weekly Family Services Log

2. Case closure form

3. Index child birth reporting form

4. Training and/or education log

18. View report of family logs

E. I am done for now and I'm ready to exit

Select a Family

1. Please select family name: (drop-down)

For privacy purposes the client's name is not kept on the same file with your responses about the client. This is the last time the client's name will be displayed. Please select the Next button to be transferred to the secure log.

FAMILY SERVICES LOG

1. Please select the calendar week for which you are completing this log (pop-up calendar)

This section will ask you about contact you have had with your client during the week for which you are reporting, specifically face-to-face and non-face-to-face contacts. You will also be asked to think back to any visits you had scheduled for the past week that did not occur. Please answer the following questions to your best ability and only in regards to the particular client assigned to this log.

2. Did you have any contact with your client during the last week?

 Yes

 No [SKIP TO 14]

Face-to-Face Contact

3. Excluding any group activities, how many face-to-face (in-person) visits did you have with your client during the past week?

NUMBER: __________

[IF NUMBER OF VISITS = 0, SKIP TO 11]

4. Excluding any group activities, how many total minutes did you spend face-to-face (in-person) with your client during the past week?

NUMBER OF MINUTES: __________

5. Did you provide any of the following materials or services to the family during the last week? CHECK ALL THAT APPLY. Please provide an approximate monetary value for any materials or supports you provided to your best ability.

 Did not provide any materials to the client

 Monetary incentives to promote or recognize participation in services( e.g., gift cards, money orders) (approximate value__________)

 Food/formula (approximate value ______________)

 Transport client (approximate mileage _____________)

 Transportation (e.g., bus fare, taxi voucher, etc.) (approximate value ________________)

 Medical supplies (e.g., breast pump, thermometer, medicine dropper) (approximate value _______________)

 Items for infant/child (e.g. diapers, books, toys) (approximate value ______________)

 Other ___________ (approximate value ____________________)

6. During any of the face-to-face contacts you had with your client during the last week, which of the following topics/activities were addressed? Please select topics from the list below. CHECK ALL THAT APPLY.

Caregiver

 Prenatal health behaviors/prenatal care

 Maternal physical health (outside of pregnancy)

 Family planning

 Tobacco, alcohol, and other drug use

 Mental health or stress

 Domestic violence or anger management

 Social support

 Job training and employment

 Education

 Economic management/financial self-sufficiency

 Housing

 Finding alternate caregivers/child care

Parenting behavior/Child outcomes

 Breastfeeding/feeding/nutrition

 Parent-child interaction

 Discipline/behavior management

 Developmentally appropriate care/routines

 Co-parenting

 Child health

 Child development

 Child/home safety

 Lead exposure in home

Family

 Public/governmental assistance

 Health insurance/Medicaid/SCHIP

7. In the past week, did you refer your client to services or provide agency contact information for any of the following areas? CHECK ALL THAT APPLY.

 None provided

 Prenatal care

 Maternal preventive care

 Family planning and reproductive health care

 Substance use (alcohol and other drugs) treatment 

 Mental health treatment

 Domestic violence shelter

 Domestic violence counseling/anger management

 Adult education services (including GED and ESL)

 Job training and employment 

 Pediatric primary care

 Housing

 Childcare 

 Early intervention services/Part C services

 Public assistance (Medicaid, SNAP, WIC, , SCHIP, TANF, etc.)

For questions 8, 9, and 10 please refer only to the longest home visit you had with your client during the last week.

8. Which of the following participated in the visit? CHECK ALL THAT APPLY

 Mother of child/pregnant woman

 Index child

 Father of child/mother’s current partner

 Other adult family member

 Other professional (nurse, early interventionist, child welfare worker, supervisor, etc.)

9. Client engagement during contact (drop-down)

 Client had little interaction other than being present

 Client was friendly but involvement was purely superficial and/or social

 Client was moderately involved in the visit

 Client was easy to engage in most conversation and activities

 Client was invested in all of the visit, asked questions, and took a very active role

10. Client follow through from previous visit (drop-down)

 N/A. No follow through anticipated/assigned

 Client could not remember previous activities/discussion/referrals

 Client remembered but did not follow through

 Client followed through incompletely

 Client followed through completely

Non-Face-to-Face Contact

11. How many times during the last week did you have any scheduled visits with the client that were cancelled or the client was not home/did not come to the visit?

NUMBER OF TIMES: _________

12. During the past week, how much total time did you spend communicating with this client via the telephone (talking, leaving messages, texting), email, writing letters, or social networking sites?

TOTAL NUMBER OF MINUTES:____________

13. How much total time did you spend traveling to and from visits with this client over the past week? This should include all visits that were completed, cancelled, or not attended by client.

TOTAL NUMBER OF MINUTES:___________

No Contact with Client

14. What was the main reason for there being no contact with your client during the past week?

1. Case closed [IF SELECTED, PROMPT i and ii]

1. Date of case closure DATE (MM/DD/YY): ___________

2. Reason for case closure. CHECK ALL THAT APPLY.

 Family moved out of service area

 Transferred to another home visiting site

 Unable to locate

 Miscarriage or fetal/child death

 Maternal death

 Excessive missed appointments/unresponsive

 Caregiver lost custody of index child

 Caregiver declined further participation (this would include going

back to work, school, getting services from other agencies, pressure from family members, etc.)

 Other

2. Scheduled in-person visit did not occur. [IF SELECTED, PROMPT i]

1. How many times did this happen during the last week? NUMBER OF TIMES:___________

3. No scheduled contact

15. How much total time did you spend traveling to and from scheduled or attempted visits with this client over the week? TOTAL NUMBER OF MINUTES: ___________

Other Activities Related to Client (All Clients)

• Excluding any group activities, Ddid other staff/providers from your program have face-to-face contact with your client this week when you were not present?

 Yes

 No [SKIP TO 16]

• Excluding any group activities, approximately how many total minutes did other staff spend face-to-face (in-person) with your client during the past week?

NUMBER OF MINUTES: __________

• What was the reason that this staff member had contact with your client?

 Conducted a home visit when I was unable to

 Provide additional services to client

Preparation:

16. How much total time did you spend preparing for and following up from contact/meetings with this client during the past week? This may include conducting research, locating resources, communicating with other providers about family, preparing handouts for a visit, completing progress notes/clinical documentation, etc.

TOTAL NUMBER OF MINUTES: ___________

Supervision:

17. Compared to your other clients, how much time would you say you spent discussing this particular client with your supervisor during the past week?

 Much less time than my average client

 Somewhat less time than my average client

 About the same amount of time as my average client

 Somewhat more time than my average client

 Much more time than my average client

18. Do you need to complete a log on additional clients?

 Yes [New form beginning with Question #1 will load]

 No

TRAINING AND EDUCATION LOG

1. Please select the calendar month for which you are completing this log: (drop down of months)

Instructions: Please complete the following questions regarding all training and/or education sessions you received as part of your current employment position during the past month.

2. Did you participate in training or education sessions within the last month?

 Yes

 No [END LOG]

The following questions should include the combined totals for all trainings and/or education sessions you participated in during the past month.

3. How many total training or education sessions did you attend within the last month?

NUMBER OF SESSIONS: _____________

4. How many total hours did you spend in training or education sessions in the last month?

NUMBER OF HOURS: _____________

5. What topics were covered during these trainings? Please choose the response(s) that most closely align with the training you received. CHECK ALL THAT APPLY.

Caregiver

 Prenatal health behaviors/prenatal care

 Postpartum physical health

 Family planning

 Tobacco, alcohol, and other drug use

 Mental health or stress

 Domestic violence or anger management

 Social support

 Housing

 Job training and employment

 Education

 Economic management/financial self-sufficiency

 Finding alternate caregivers/child care

 Other ____________________

Parenting behavior/Child outcomes

 Breastfeeding/feeding/nutrition

 Parent-child interaction

 Discipline/behavior management

 Developmentally appropriate care/routines

 Co-parenting

 Child health

 Child development

 Child abuse/neglect/maltreatment

 Other ____________________

Family

 Public/governmental assistance

 Medicaid/SCHIP

 Child/home safety

 Lead in home

 Other ____________________

Home Visitor

 General clinical and communication skills

 Stress management for home visitor

 Cultural sensitivity/diversity

 Other ____________________

6. Did the training involve any of the following? CHECK ALL THAT APPLY.

 Reading material

 Lecture

 Demonstration

 Test or assessment of knowledge gained

 Role playing/practice/behavioral rehearsal [IF SELECTED, PROMPT i]

 None of the above

1. Was there an observation of the role play or rehearsal by the trainer?

 Yes

 No

 Unknown

• IF YES, PROMPT. Were there set performance standards you were required to meet (e.g., scores, ratings, etc.)?

 Yes

 No

 Unknown

Case Closure Form

1. Please select the family name for which you are reporting a case closure (drop-down family name)

2. Date of case closure: (pop-up calendar)

3. Reason for case closure. CHECK ALL THAT APPLY.

 Family moved out of service area

 Transferred to another home visiting site

 Unable to locate

 Miscarriage or fetal/child death

 Maternal death

 Excessive missed appointments/unresponsive

 Caregiver lost custody of index child

 Caregiver declined further participation (this would include going back to work, school,

getting services from other agencies, pressure from family members, etc.)

 Other

If you have spent any time on this case this week in face-to-face contact or non-face-to-face work related to the case you should complete a family service log for this week.

Would you like to complete a Family Services log for this family right now?

 Yes [Family Service Log will load]

 No [End Log]

Birth of Index Child Log

• Infant DOB: (pop-up calendar)