Form B Detail Sheets

Table of Contents

Attachement B:
Domain Specific Measures

Core Measures 4
Capacity Building Measures 8
Activity Data Collection Form for Selected Measures 18

Population Domain Measures
Women’s/ Maternal Health 19
Perinatal Infant Health 26
Child Health 32
Children and Youth with Special Health Care Needs 40
Adolescent Health 48
Life Course/ Cross Cutting 55

Program-Specific Measures

Division of MCH Workforce Development 64
Div. of Child Adolescent, & Family Health – Emergency Medical Services for Children Program 109
Division of Healthy Start and Perinatal Services 142
Div. of Children with Special Health Needs – Family to Family Health Information Ctr Program 154

Health Resources and Services Administration

Maternal and Child Health Bureau

Discretionary Grant Performance Measures

OMB No. 0915-0298

Expires: _________

Attachment B

Part 1- Detail Sheets

OMB Clearance Package

Updated DGIS Performance Measures, Numbering by Domain (All Performance Measures are revised from prior OMB package)
Performance Measure	New/Revised Measure	Prior PM Number (if applicable)		Topic
Core
Core 1	New		N/A	Grant Impact
Core 2	New		N/A	Quality Improvement
Core 3	New		N/A	Health Equity – MCH Outcomes
Capacity Building
CB 1	New		N/A	State Capacity for Advancing the Health of MCH Populations
CB 2	New		N/A	Technical Assistance
CB 3	New		N/A	Impact Measurement
CB 4	Revised		5	Sustainability
CB 5	Revised		3, 4	Scientific Publications
CB 6	New		N/A	Products
Women’s/ Maternal Health
WMH 1	New		N/A	Prenatal Care
WMH 2	New		N/A	Perinatal/ Postpartum Care
WMH 3	New		N/A	Well Woman Visit/ Preventive Health Care
WMH 4	New		N/A	Depression Screening
Perinatal Infant Health
PIH 1	New		N/A	Safe Sleep
PIH 2	New		N/A	Breast Feeding
PIH 3	New		N/A	Newborn Screening
Child Health
CH 1	New		N/A	Well Child Visit
CH 2	New		N/A	Quality of Well Child Visit
CH 3	New		N/A	Developmental Screening
CH 4	New		N/A	Injury Prevention
Children and Youth with Special Health Care Needs
CSHCN 1	Revised		7	Family Engagement
CSHCN 2	Revised		40, 41	Access to and Use of Medical Home
CSHCN 3	New		N/A	Transition to Adult Health Care
Adolescent Health
AH 1	New		N/A	Adolescent Well Visit
AH 2	New		N/A	Injury Prevention
AH 3	New		N/A	Screening for Major Depressive Disorder
Life Course/ Cross Cutting
LC 1	New		N/A	Adequate Health Insurance Coverage
LC 2	Revised		39	Tobacco and eCigarette Cessation
LC 3	New		N/A	Oral Health

Core 1 Performance Measure Goal: Grant Impact Level: Grantee Domain: Core	The percent of programs meeting the stated aims of their grant at the end of the current grant cycle
GOAL	To ensure that planned grant impact was met.
MEASURE	The percent of MCHB funded projects meeting their stated objectives.
DEFINITION	Tier 1: Have you met the planned objectives as stated at the beginning of the grant cycle? Prepopulated with the objectives from FOA: Did you meet objective 1__________? Y/N Did you meet objective 2__________? Y/N
BENCHMARK DATA SOURCES	N/A
GRANTEE DATA SOURCES	Grantee self-reported
SIGNIFICANCE

Core 2 Performance Measure Goal: Quality Improvement Level: Grantee Domain: Core	The percent of programs engaging in quality improvement and through what means, and related outcomes.
GOAL	To measure quality improvement initiatives.
MEASURE	The percent of MCHB funded projects implementing quality improvement initiatives.
DEFINITION	Tier 1: Are you implementing quality improvement (QI) initiatives in your program? Yes No Tier 2: QI initiative: What type of QI structure do you have? (Check all that apply) Team established within a division, office, department, etc. of an organization to improve a process, policy, program, etc. Team within and across an organization focused on organizational improvement Cross sectorial collaborative across multiple organizations What types of aims are included in your QI initiative? (Check all that apply) Population health Improve service delivery (process or program) Improve client satisfaction/ outcomes Improve work flow Policy improvement Reducing variation or errors Tier 3: Implementation Are QI goals directly aligned with organization’s strategic goals? Y/ N Has the QI team received training in QI? Y/N Do you have metrics to track improvement? Y/N Which methodology are you utilizing for quality improvement? (Check all that apply) Plan, Do, Study, Act Cycles Lean Six Sigma Other: _________________ Tier 4: What are the related outcomes? Is there data to support improvement in population health as a result of the QI activities? Y/N Is there data to support organizational improvement as a result of QI activities? Y/N Is there data to support improvement in cross sectorial collaboration as a result of QI activities? Y/N
BENCHMARK DATA SOURCES	N/A
GRANTEE DATA SOURCES	Grantee self-reported.
SIGNIFICANCE

Core 3 Performance Measure Goal: Health Equity Level: Grantee Domain: Capacity Building	The percent of programs promoting and/ or facilitating improving health equity.
GOAL	To ensure MCHB grantees have established specific aims related to improving health equity.
MEASURE	The percent of MCHB funded projects with specific measurable aims related to promoting health equity.
DEFINITION	Tier 1: Are you promoting and/ or facilitating health equity in your program? Yes No Tier 2: Please select within which of the following domains your program addresses health equity (check all that apply): Income Race Ethnicity Language Socioeconomic Status Health Status Disability Sexual Orientation Sex Gender Age Geography – Rural/ Urban Other: _________ Tier 3: Implementation Has your program set stated goal/ objectives for health equity? Y/N If yes, what are those aims? _____________ Tier 4: What are the related outcomes? % of programs that met stated goals/ objectives around health equity Numerator: # of programs that met stated specific aims around health equity Denominator: # of programs that set specific aims around health equity * Health equity exists when challenges and barriers have been removed for those groups who experience greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.
BENCHMARK DATA SOURCES	N/A
GRANTEE DATA SOURCES	Grantee self-reported.
SIGNIFICANCE	Health equity is achieved when every individual has the opportunity to attain his or her full health potential and no one is “disadvantaged from achieving this potential because of social position or socially determined consequences.” Achieving health equity is a top priority in the United States.

CB 1 Performance Measure Goal: State capacity for advancing the health of MCH populations (for National programs) Level: Grantee Domain: Capacity Building	The percent of programs promoting and facilitating state capacity for advancing the health of MCH populations.
GOAL	To ensure adequate and increasing state capacity for advancing the health of MCH populations.
MEASURE	The percent of MCHB-funded projects of a national scale promoting and facilitating state capacity for advancing the health of MCH populations, and through what processes.
DEFINITION	Tier 1: Are you promoting and facilitating state capacity for advancing the health of MCH populations for _________’s* priority topic? Yes No *prepopulated with program focus
	Tier 2: Through what activities are you promoting and facilitating state capacity for advancing the health of MCH populations? Delivery of training on program priority topic Support state strategic planning activities Serve as expert and champion on the priority topic Facilitate state level partnerships to advance priority topics Maintain consistent state-level staffing support for priority topic (State-level programs only) Collect data to track changes in prevalence of program priority issues Utilize available data to track changes in prevalence of program priority issue on national/ regional level Issue model standards of practice for use in the clinical setting Tier 3: Implementation # of professionals trained on program priority topic How frequently are data collected and analyzed to monitor status and refine strategies?: Less frequently than annually Bi-annual Quarterly Monthly # of MOUs between State agencies addressing priority area
	# of State agencies/departments participating on priority area. This includes the following key state agencies (check all that apply): Commissions/ Task Forces MCH/CSHCN Genetics Newborn Screening Early Hearing and Detection EMSC Oral Health Developmental Disabilities Medicaid Mental & Behavioral Health Housing Early Intervention/Head Start Education Child Care Juvenile Justice/Judicial System Foster Care/Adoption Agency Transportation Higher Education Law Enforcement Children’s Cabinet Other (Specify______) Have model standards of practice been established to increase integration of MCH priority issue into clinical setting? Y/N Development or identification of reimbursable services codes to cover delivery of clinical services on MCH priority topic? Y/N Inclusion of specific language in Medicaid managed care contracts to assure coverage of payment for clinical services on MCH priority topic? Y/N
	Tier 4: What are the related outcomes? (National Programs Only) % of state/ jurisdictions have a strategic plan on program priority topic % of states/ jurisdictions receiving training on this program topic % of states/ jurisdictions which have state FTEs designated for this MCH topic % of MCH programs have an identified state lead designated on this topic % of states/ jurisdictions utilizing reimbursable services codes to cover delivery of clinical services on MCH priority topic? % of states/jurisdictions which report progress on strategic plan goals and objectives?
BENCHMARK DATA SOURCES	N/A
GRANTEE DATA SOURCES	Grantee Self-Reported.

CB 2 Performance Measure Goal: Technical Assistance Level: Grantee Domain: Capacity Building	The percent of programs providing technical assistance on MCH priority topics.
GOAL	To ensure supportive programming for technical assistance.
MEASURE	The percent of MCHB funded projects providing technical assistance, on which MCH priority topics, and to whom.
DEFINITION	Tier 1: Are you providing technical assistance (TA) though your program? Yes No Tier 2: To whom are you providing TA (check all that apply)? Participants/ Public Providers/ Health Care Professionals Local/ Community Partners State/ National Partners *Technical Assistant refers to collaborative problem solving on a range of issues, which may include program development, program evaluation, needs assessment, and policy or guideline formulation. It may include administrative services, site visitation, and review or advisory functions. TA may be a one-time or ongoing activity of brief or extended frequency.
	Tier 3: Implementation (populated from prior domain questions) # CSHCN/Developmental Disabilities TA # Autism TA # Prenatal Care TA # Perinatal/ Postpartum Care TA # Maternal and Women’s Depression Screening TA # Safe Sleep TA # Breastfeeding TA # Newborn Screening TA # Genetics TA # Quality of Well Child Visit TA # Well Visit TA # Injury Prevention TA # Family Engagement TA # Medical Home TA # Transition TA # Adolescent Major Depressive Disorder Screening TA # Health Equity TA # Adequate health insurance coverage TA # Tobacco and eCigarette Use TA # Oral Health TA # Nutrition TA # Data Research and Evaluation TA # Other TA (Please specify additional topics:____________) Tier 4: What are the related outcomes? (populated from prior questions) # receiving TA # technical assistance activities # TA activities by target audience (Local, Title V, Other state agencies,/ partners, Regional, National, International)
GRANTEE DATA SOURCES	Grantee self-reported.
SIGNIFICANCE	National Resource Centers, Policy Centers, leadership training institutes and many other MCHB discretionary grantees provide technical assistance and training to various target audiences, including grantees, health care providers, state agencies, community-based programs, program beneficiaries, and the public as a way of improving skills, increasing the MCH knowledge base, and thus improving capacity to adequately serve the needs of MCH populations and improve their outcomes.

Data Collection Form for #CB 2

The form below will be prepopulated by TA selected in domain-specific measures.

All measures for which a grantee reported that they provide TA will be triggered in this table.

Instructions: Please report the number of TA activities for each audience. If TA activities reached multiple audiences, please count for each audience, without concern for duplication. Participants/ public include infants, children, adolescents, adult participants, and families. Community/ local partners are considered to be community-based organizations or municipal or city divisions, programs, or organizations including schools. State or national partners include state or federal divisions or programs, as well as statewide or national organizations, such as non-profit organizations and non-governmental organizations.

Technical Assistance Area	Participants/ Public	Providers/ Health Care Professionals	Community/ Local Partners	State or National Partners
Prenatal Care
Perinatal/ Postpartum Care
Maternal and Women’s Depression Screening
Safe Sleep
Breastfeeding
Newborn Screening
Genetics
Quality of Well Child Visit
Well Visit
Injury Prevention
Family Engagement
Medical Home
Transition
Adolescent Major Depressive Disorder Screening
Health Equity
Adequate health insurance coverage
Tobacco and eCigarette Use
Oral Health
Nutrition
Data Research and Evaluation
Other

CB 3 Performance Measure Goal: Impact Measurement Level: Grantee Domain: Capacity Building	The percent of grantees that collect and analyze data on the impact of their grants on the field.
GOAL	To ensure supportive programming for impact measurement.
MEASURE	The percent of grantees that collect and analyze data on the impact of their grants on the field, and the methods used to collect data.
DEFINITION	Tier 1: Are you collecting and analyzing data related to impact measurement in your program? Yes No Tier 2: How are you measuring impact? Conduct participant surveys Collect client level data Qualitative assessments Case reports Other:______________ Tier 3: Implementation List of tools used Outcomes of qualitative assessment # of participant surveys # of clients whose level data collected # of case reports Tier 4: What are the related outcomes? % of grantees that collect data on the impact of their grants on the field (and methods used to collect data) Numerator: # of grantees that collect data on the impact of their grants on the field Denominator: # of grantees How is data collected:___________________________ % of grantees that collect and analyze data on the impact of their grants on the field (and methods used to analyze data) Numerator: # of grantees that analyze data on the impact of their grants on the field Denominator: # of grantees How is data analyzed:_________________________
GRANTEE DATA SOURCES	Grantee self-reported.
SIGNIFICANCE	Impact as referenced here is a change in condition or status of life. This can include a change in health, social, economic or environmental condition. Examples may include improved health for a community/population or a reduction in disparities for a specific disease or increased adoption of a practice.

CB 4 Performance Measure Goal: Sustainability Level: Grantee Domain: Capacity Building	The percent of MCHB funded initiatives working to promote sustainability of their programs or initiatives beyond the life of MCHB funding.
GOAL	To ensure sustainability of programs or initiatives over time, beyond the duration of MCHB funding.
MEASURE	The percent of MCHB funded initiatives working to promote sustainability of their programs or initiatives beyond the life of MCHB funding, and through what methods.
DEFINITION	Tier 1: Are you addressing sustainability in your program? Yes No Tier 2: Through what processes/ mechanisms are you addressing sustainability? A written sustainability plan is in place within two years of the MCHB award with goals, objectives, action steps, and timelines to monitor plan progress Staff and leaders in the organization engage and build partnerships with consumers, and other key stakeholders in the community, in the early project planning, and I sustainability planning and implementation processes There is support for the MCHB-funded program or initiative within the parent agency or organization, including from individuals with planning and decision making authority There is an advisory group or a formal board that includes family, community and state partners, and other stakeholders who can leverage resources or otherwise help to sustain the successful aspects of the program or initiative The program’s successes and identification of needs are communicated within and outside the organization among partners and the public, using various internal communication, outreach, and marketing strategies The grantee identified, actively sought out, and obtained other funding sources and in-kind resources to sustain the entire MCHB-funded program or initiative Policies and procedures developed for the successful aspects of the program or initiative are incorporated into the parent or another organization’s system of programs and services The responsibilities for carrying out key successful aspects of the program or initiative have begun to be transferred to permanent staff positions in other ongoing programs or organizations The grantee has secured financial or in-kind support from within the parent organization or external organizations to sustain the successful aspects of the MCHB-funded program or initiative Tier 3: Implementation N/A Tier 4: What are the related outcomes? % of grants that have sustainability plans
BENCHMARK DATA SOURCES	N/A
GRANTEE DATA SOURCES	Grantee self-reported.
SIGNIFICANCE	In recognition of the increasing call for recipients of public funds to sustain their programs after initial funding ends, MCHB encourages grantees to work toward sustainability throughout their grant periods. A number of different terms and explanations have been used as operational components of sustainability. These components fall into four major categories, each emphasizing a distinct focal point as being at the heart of the sustainability process: (1) adherence to program principles and objectives, (2) organizational integration, (3) maintenance of health benefits, and (4) State or community capacity building. Specific recommended actions that can help grantees build toward each of these four sustainability components are included as the Tier 2 data elements for this measure.

CB 5 PERFORMANCE MEASURE Goal: Scientific Publications Level: Grantee Domain: Capacity Building	The percent of programs supporting the production of scientific publications and through what means, and related outcomes.
GOAL	To ensure supportive programming for the production of scientific publications.
MEASURE	The percent of MCHB funded projects programs supporting the production of scientific publications.
DEFINITION	Tier 1: Are you supporting the production of scientific publications in your program? Yes No Tier 2: Indicate the categories of scientific publication that have been produced with grant support (either fully or partially) during the reporting period. Submitted In press Published Tier 3: How many are reached through those activities? # of scientific/ peer-reviewed publications Tier 4: How, if at all, have these publications been disseminated (check all that apply)? Note: research only; include this as Part B of publications form TV/ Radio interview(s) Newspaper interview(s) Online publication interview(s) Press release Social Networking sites Listservs Presentation at conference (poster, abstract, presentation) Websites
GRANTEE DATA SOURCES	Grantee self-reported.
SIGNIFICANCE	Advancing the field of MCH based on evidence-based, field-tested quality products. Collection of the types of and dissemination of MCH products and publications is crucial for advancing the field. This measure addresses the production and quality of new informational resources created by grantees for families, professionals, other providers, and the public.

CB 6 Performance Measure Goal: Products Level: Grantee Domain: Capacity Building	The percent of programs supporting the development of informational products and through what means, and related outcomes.
GOAL	To ensure supportive programming for the development of informational products.
MEASURE	The percent of MCHB funded projects supporting the development of informational products, and through what processes.
DEFINITION	Tier 1: Are you creating products as part of your MCHB-supported program? Yes No Tier 2: Indicate the categories of products that have been produced with grant support (either fully or partially) during the reporting period. Count the original completed product, not each time it is disseminated or presented. Books Book chapters Reports and monographs (including policy briefs, best practice reports, white papers) Conference presentations and posters presented Web-based products (website, blogs, webinars, newsletters, distance learning modules, wikis, RSS feeds, social networking sites) Excluding video/ audio products that are posted online post-production Audio/ Video products (podcasts, produced videos, video clips.CD-ROMs, CDs, or audio) Press communications (TV/ Radio interviews, newspaper interviews, public service announcements, and editorial articles) Newsletters (electronic or print) Pamphlets, brochures, or fact sheets Academic course development Distance learning modules Doctoral dissertations/ Master’s theses Other: ________________ Tier 3: Implementation of products # products created in each category Tier 4: What are the related outcomes? N/A
GRANTEE DATA SOURCES	Grantee self-reported.
SIGNIFICANCE	Advancing the field of MCH based on evidence-based, field-tested quality products. Collection of the types of and dissemination of MCH products and publications is crucial for advancing the field. This PM addresses the production and quality of new informational resources created by grantees for families, professionals, other providers, and the public.

Table 1: Activity Data Collection Form for Selected Measures

Please use the form below to identify what services you provide to each segment. For those you provide the service to, please provide the number of services provided (i.e. # of women receiving referrals or # of partners receiving TA). For those services you do not provide, or segments you do not reach, please leave the cell blank.

	Participants/ Public	Providers/ Health Care Professionals	Community/ Local Partners	State or National Partners
Technical Assistance
Training
Product Development
Research/ Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Screening/ Assessment
Referral/ care coordination
Direct Service
Quality improvement initiatives

WHM 1 PERFORMANCE MEASURE Goal: Prenatal Care Level: Grantee Domain: Women’s/ Maternal Health	The percent of programs promoting and/or facilitating timely prenatal care.
GOAL	To ensure supportive programming for prenatal care.
MEASURE	The percent of MCHB funded projects addressing prenatal care. The percent of pregnant program participants who receive prenatal care beginning in the first trimester.
DEFINITION	Tier 1: Are you addressing prenatal care in your program? Yes No Tier 2: Through what processes/ mechanisms are you addressing prenatal care? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of pregnant women who receive prenatal care beginning in the first trimester Numerator: Pregnant program participants who began prenatal care in the first trimester of pregnancy. Denominator: Pregnant program participants who were enrolled prenatally.
BENCHMARK DATA SOURCES	Related to MICH Objective #10: Increase the proportion of pregnant women who receive prenatal care beginning in the first trimester (Baseline: 70.8% in 2007, Target: 77.9%)
GRANTEE DATA SOURCES	Title V Ntnl Outcome Measure #1, Healthy People 2020 MICH-10
SIGNIFICANCE	Entry of prenatal care during the first trimester is important to ensuring a healthy pregnancy for both the mother and child. Women who receive delayed prenatal care (entry after the first 12 weeks) are at risk for having undetected complications in pregnancy that can result in undesirable consequences for both mother and baby.
WMH 2 PERFORMANCE MEASURE Goal: Perinatal/ Postpartum Care Level: Grantee Domain: Women’s/ Maternal Health		The percent of programs promoting and/ or facilitating timely postpartum care.
GOAL		To ensure supportive programming for postpartum care.
MEASURE		The percent of MCHB funded projects addressing perinatal and postpartum care. The percent of pregnant women with a postpartum visit within 8 weeks of delivery.
DEFINITION		Tier 1: Are you promoting and/ or facilitating timely postpartum care in your program? Yes No Tier 2: Through what processes/ mechanisms are you promoting and/ or facilitating perinatal and postpartum care? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of pregnant women with a postpartum visit within 4 to 6 weeks of delivery Numerator: Program participants included in the denominator who had a postpartum visit within 4 to 6 weeks of delivery Denominator: Women program participants who enrolled before 6 weeks post-delivery and who delivered 6 weeks or more prior to the end of the reporting period.
BENCHMARK DATA SOURCES		Related to Healthy People 2020 MICH- 19: Increase the proportion of women giving birth who attend a postpartum care visit with a health worker.
GRANTEE DATA SOURCES		Pregnancy Risk Assessment Monitoring System
SIGNIFICANCE		Perinatal care is important for mothers to receive to ensure they are getting adequate reproductive health services from trained professionals. Families should be trained on family planning, pre-conceptual counseling, newborn care, and care for the woman in the postpartum period. Postpartum care is important for the mother and new baby following birth following the many new changes that occur; physically, physiologically, psychologically, and mentally. Postpartum care is targeted to promote maternal well-being and help transition to motherhood along with family planning to include significant others. ACOG Committee on Obstetric Practice. Guidelines for Perinatal Care (7th Edition, p. 207) state that 4 to 6 weeks after delivery, women should have a postpartum visit with her doctor.

WMH 3 Performance Measure Goal: Well Woman Visit/ Preventive Health Care Level: Grantee Domain: Women’s/ Maternal Health	The percent of programs promoting and/ or facilitating well woman visits/ preventive health care.
GOAL	To ensure supportive programming for well woman visits/ preventive health care.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating well woman visits/ preventive health care and through what processes.
DEFINITION	Tier 1: Are you promoting and/ or facilitating well woman visits/ preventive health care in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating well woman visits/ preventive health care? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of women with a well woman/ preventative visit in the past year. Numerator: Women program participants who received a well-woman or preventive visit in the past 12 months (includes prenatal and postpartum visit) Denominator: Women program participants Definition: A participant is considered to have a well-woman or preventive visit and included in the numerator if she has a documented health assessment visit where she obtained recommended preventive services that are age and developmentally appropriate within twelve months of her last contact with the Program. For purposes of reporting, a prenatal visit or postpartum visit during the twelve month period would meet the standard.
BENCHMARK DATA SOURCES	Behavioral Risk Factor Surveillance System (BRFSS) Last Check Up within Prior Year (Nationwide, 2013): 68.2%
GRANTEE DATA SOURCES	Title V National Performance Measure #1
SIGNIFICANCE	A well woman visit is a way to make sure an individual is staying healthy. These include a full checkup, separate from a visit for sickness or injury. The focus is on preventive care which includes, but is not limited to, appropriate assessment, immunizations, screenings, education, and counseling.

WMH 4 Performance Measure Goal: Depression Screening Level: Grantee Domain: Women’s/ Maternal Health	The percent of programs promoting and/ or facilitating depression screening.
GOAL	To ensure supportive programming for depression screening.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating depression screening and through what processes.
DEFINITION	Tier 1: Are you promoting and/ or facilitating depression screening in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating depression screening? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of women screened for depression using a validated tool Numerator: Program participants included in the denominator who were screened for depression using a validated tool within the reporting period Denominator: Women program participants % of women who screened positive for depression who receive a referral for services Numerator: Women program participants who screened positive for depression who received a referral for services. Denominator: Women program participants who screened positive for depression.
BENCHMARK DATA SOURCES	Related to Healthy People 2020 MICH #34 Objective: (Developmental) Decrease the proportion of women delivering a live birth who experience postpartum depressive symptoms.
GRANTEE DATA SOURCES	Home Visiting Performance Measure
SIGNIFICANCE	Fewer than half the cases of postpartum depression are recognized every year. Yet, postpartum depression occurs in nearly 20% of women who have recently given birth. Screening is important not only for the mother, but for children’s outcomes as well. Children with depressed mothers are likely to have delayed social and behavioral development.

PIH 1 Performance Measure Goal: Safe Sleep Level: Grantee Domain: Perinatal Infant Health	The percent of Healthy Start participants who engage in safe sleep practices.
GOAL	To ensure supportive programming for safe sleep practices.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating safe sleep practices.
DEFINITION	Tier 1: Are you promoting and/ or facilitating safe sleep in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating safe sleep? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of infants placed to sleep following safe sleep practices Numerator: Number of Healthy Start (HS) child participant (aged 0-12 months) whose parent reports that they are most often or always placed to sleep following safe sleep practices. Denominator: Number of HS child participants aged 0 to 12 months old. A participant is considered to engage in safe sleep practices and included in the numerator if it is reported that the baby is most often placed to sleep on their back and with no bed-sharing.
BENCHMARK DATA SOURCES	Related to MICH Objective #20: Increase the proportion of infants placed to sleep on their backs (Baseline: 69.0%, Target: 75.9%), Pregnancy Risk Assessment Monitoring System (PRAMS).
GRANTEE DATA SOURCES	Title V National Performance Measure #5, Home Visiting Performance Measure
SIGNIFICANCE	Sleep-related infant deaths, called Sudden Unexpected Infant Deaths (SUIDS), are the leading cause of infant death after the first month of life. Risk of SUIDS increases when babies are placed on their side or stomach to sleep. Placing babies on their back, on a firm surface without loose bedding or soft objects, as well as no bed-sharing are the recommended practices to follow according to American Assoc. of Pediatrics.

PIH 2 PERFORMANCE MEASURE Goal: Breastfeeding Level: Grantee Domain: Perinatal Infant Health	The percent of programs promoting and/ or facilitating breastfeeding.
GOAL	To ensure supportive programming for breastfeeding.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating breastfeeding.
DEFINITION	Tier 1: Are you promoting and/ or facilitating breastfeeding in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating breastfeeding? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of infants who are ever breastfed Numerator: Infant participants whose parent reports they were ever breastfed or fed breastmilk to their infant. Denominator: Infant children <24 months of women program participants who were enrolled prenatally. % of infants breastfed through 6 months Numerator: Number of HS child participants whose parent reports they were breastfed or fed breast milk at 6 months of age. Denominator: Number of child participants aged 6 -24 months whose mother was enrolled prenatally or at the time of birth..
BENCHMARK DATA SOURCES	Objective # MICH-21.1: Increase the proportion of children who are ever breastfed. (Baseline: 74% in 2006, Target: 81.9%). MICH-21.2: Increase the proportion of infants who are breastfed at 6 months (Baseline: 43.5% in 2006, Target: 60.6%). MICH-21.3: Increase the proportion of infants who are breastfed at 1 year (Baseline: 34.1% in 2006, Target: 34.1%). MICH-21.4: Increase the proportion of infants who are breastfed exclusively through 3 months (Baseline: 33.6% in 2006, Target: 46.2%). MICH-21.5: Increase the proportion of infants who are breastfed exclusively at 6 months (Baseline: 14.1% in 2006, Target: 25.5%).
GRANTEE DATA SOURCES	Title V NPM #4, Home Visiting Performance Measure, Healthy Start Benchmark, Healthy People 2020, MICH-21.5, National Immunization Survey (NIS).
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 grown and development for approximately the first 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.

PIH 3 Performance Measure Goal: Newborn Screening Level: Grantee Domain: Perinatal Infant Health	Percent of programs promoting newborn screenings and follow-up.
GOAL	To ensure supportive programming for newborn screenings.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating newborn screening and follow-up.
DEFINITION	Tier 1: Are you promoting and/or facilitating newborn screening and follow-up in your program? Yes No Tier 2: Through what processes/ mechanisms are you promoting or facilitating newborn screening and follow-up? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of eligible newborns screened with timely notification for out of range screens Numerator: # of eligible newborns screened with out of range results whose caregivers receive timely notification Denominator: # of eligible newborns screened with out of range results % of eligible newborns screened with timely notification for out of range screens who are followed up in a timely manner Numerator: # of eligible newborns screened with out of range results whose caregivers receive timely notification and receive timely follow up Denominator: # of eligible newborns screened with out of range results whose caregivers receive timely notification
BENCHMARK DATA SOURCES	Objective # MICH-32: Increase appropriate newborn-blood spot screening and follow-up testing (Baseline: 98.3% in 2006, Target: 100%)
GRANTEE DATA SOURCES	Title V National Outcome Measure #12
SIGNIFICANCE	Newborn screening detects thousands of babies each year with potentially devastating, but treatable disorders. The benefits of newborn screening depend upon timely collection of the newborn blood-spots or administration of a point-of-care test (pulse oximeter for critical congenital heart disease), receipt of the newborn blood spot at the laboratory, testing of the newborn blood spot, and reporting out all results. Timely detecting prevents death and other significant health complications.

CH 1 Performance Measure Goal: Well-Child Visit Level: Grantee Domain: Child Health	The percent of programs promoting and/ or facilitating well-child visits.
GOAL	To ensure supportive programming for well-child visits.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating well-child visits.
DEFINITION	Tier 1: Are you promoting and/ or facilitating well-child visits in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating well-child visits? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of children who received a well care visit in the reporting year Numerator: Child program participants who received a well care visit in the reporting year Denominator: Child program participants in the reporting year % of children enrolled in Medicaid/ CHIP with at least one well care visit in the past year Numerator: Medicaid/ CHIP-enrolled child program participants who received a well-child visit in the reporting year. Denominator: Medicaid/ CHIP-enrolled child program participants in the reporting year
BENCHMARK DATA SOURCES	National Survey of Children’s Health K4Q20
GRANTEE DATA SOURCES	Title V National Performance Measure #10,
SIGNIFICANCE	As childhood is a time of growth and development, it is important that children are seeing their pediatrician on a regular basis.
CH 2 Performance Measure Goal: Quality of Well Child Visit Level: Grantee Domain: Child Health		The percent of programs promoting and/ or facilitating quality of well-child visits.
GOAL		To ensure supportive programming for quality of well child visits.
MEASURE		The percent of MCHB funded projects promoting or facilitating quality of well child visits.
DEFINITION		Tier 1: Are you addressing the quality of well child visits in your program? Yes No Tier 2: Through what activities are you addressing quality of well child visits? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Quality improvement initiatives Tier 3: How many are reached through those activities? # receiving TA # receiving professional/organizational development training # product disseminated # reached while guideline setting Tier 4: What are the related outcomes? % providers trained in conducting a quality well-child visit Numerator: # of providers trained Denominator:# of providers targeted through the program
BENCHMARK DATA SOURCES		N/A
GRANTEE DATA SOURCES		Grantee self-reported.
SIGNIFICANCE		Children grow and develop very rapidly so it is important they see a pediatrician on a regular basis. Each visit should include a complete physical examination, record of height and weight, and information regarding hearing, vision, and annual screenings.

CH 3 Performance Measure Goal: Developmental Screening Level: Grantee Domain: Child Health	Percent of programs promoting developmental screenings and follow-up for children.
GOAL	To ensure supportive programming for developmental screenings.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating developmental screening and follow-up for children.
DEFINITION	Tier 1: Are you promoting and/or facilitating developmental screening and follow-up in your program? Yes No Tier 2: Through what processes/ mechanisms are you promoting or facilitating developmental screening and follow-up? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of children 9 through 71 months receiving a developmental screening using a parental-completed tool? Numerator: Children of program participants aged 9 to 71 months who have received a developmental screening using a parent/ caretaker-completed tool Denominator: Children, aged 9 to 71 months, of program participants
BENCHMARK DATA SOURCES	National Survey of Children's Health Indicator 4.16: Developmental screening during health care visit, age 10 months-5 years (2011/2012)
GRANTEE DATA SOURCES	Title V National Performance Measure #6, Title V National Outcome Measure #12
SIGNIFICANCE	Early identification of developmental disorders is critical to the well-being of children and their families. It is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health care professionals. The early identification of developmental problems should lead to further developmental and medical evaluation, diagnosis, and treatment, including early developmental intervention. Children diagnosed with developmental disorders should be identified as children with special health care needs, and chronic-condition management should be initiated. Identification of a developmental disorder and its underlying etiology may also drive a range of treatment planning, from medical treatment of the child to family planning for his or her parents.

CH 4 Performance Measure Goal: Injury Prevention Level: Grantee Domain: Child Health	The percent of programs promoting and/ or facilitating injury prevention among children.
GOAL	To ensure supportive programming for injury prevention among children.
MEASURE	The percent of MCHB funded projects addressing injury prevention and through what processes.
DEFINITION	Tier 1: Are you promoting and/ or facilitating injury prevention among children in your program? Yes No Tier 2: Through what processes/ mechanisms are you addressing injury-prevention? See data collection form. Technical Assistance Training Research/ dissemination Peer-reviewed publications Outreach/ Information Dissemination/ Education Referral/ care coordination Quality improvement initiatives Use of fatality review data Please check which child safety domains which program activities were designed to impact: Motor Vehicle Traffic Suicide/ Self-Harm Falls Bullying Child Maltreatment Unintentional Poisoning Prescription drug overdose Traumatic Brain Injury Drowning Other Tier 3: How many are reached through those activities? # receiving TA # receiving professional/organizational development training # of peer-reviewed publications published # receiving information and education through outreach # referred/ managed % using fatality review data See data collection form. Tier 4: What are the related outcomes? Rate of injury-related hospitalization to children ages 1-9. Numerator: Injury-related hospitalizations to children ages 1-9 Denominator: Children ages 1-9 in the target population Target Population: __________________________ Percent of children ages 6-11 missing 5 or more days of school because of illness or injury. Numerator: # of children ages 6-11 missing 5 or more days of school Denominator: Total number of children ages 6-11 represented in National Survey of Children’s Health results Dataset reporting from: ___________________
BENCHMARK DATA SOURCES	Related to Healthy People 2020 Injury and Violence Prevention objectives 1 through 39.
GRANTEE DATA SOURCES	Title V National Performance Measure #7 Child Injury, AHRQ Healthcare Cost and Utilization Project: National Inpatient Sample or State Inpatient Database; National Survey of Children’s Health, Question G1 in the 6-11 year old survey
SIGNIFICANCE	Two dozen children die every day in the United States from an unintentional or intentional injury. In addition, millions of children survive their injury and have to live the rest of their lives with negative health effects. Although there has been much progress in the United States in reducing child injuries, more is needed.

Data Collection Form for Detail Sheet # CH 4

Please use the form below to report what services you provided in which safety domains, and how many received those services. Please use the space provided for notes to specify the recipients of each type of service.

	Motor Vehicle Traffic	Suicide/ Self-Harm	Falls	Bullying	Child Maltreatment	Unintentional Poisoning	Prescription drug overdose	Traumatic Brain Injury	Drowning	Other (Specify)
Technical Assistance
Training
Research/ dissemination
Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Referral/ care coordination
Quality improvement initiatives
Use of fatality review data
Notes:

CSHCN 1 Performance Measure Goal: Family Engagement Level: Grantee Domain: CSHCN	The percent of programs promoting and/ or facilitating family engagement among children and youth with special health care needs.
GOAL	To ensure supportive programming for family engagement among children and youth with special health care needs.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating family engagement among children and youth with special health care needs.
DEFINITION	Tier 1: Tier 1: Are you promoting and/ or facilitating family engagement among children and youth with special health care needs in your program? Yes No Tier 2: Through what processes/ mechanisms are you promoting and/ or facilitating family engagement? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives (continued on next page )
DEFINITION (continued)	Tier 4: What are the related outcomes? % of target population with family and CSHCN leaders with meaningful roles on community/ state/ regional/ national level teams focused on CSHCN systems Numerator: # of Family and CSHCN leaders with meaningful roles on community/state/regional/national level teams focused on CSHCN systems Denominator: # of CSHCN in catchment area % of racial and ethnic family and CSCHN leaders who are trained and serving on community/ state/ regional/ national level teams focused on CSHCN systems Numerator: #of racial and ethnic family and CSHCN leaders trained and serving on community/state/ regional/ national level teams focused on CSHCN systems Denominator: # of CSHCN in catchment area % of target population with family of CSHCN participating in information exchange forums Numerator: # participating in information exchange forums Denominator: # CSHCN in catchment area % of family and CSCHN leaders trained who report increased knowledge, skill, ability and self-efficacy to serve as leaders on systems-level teams Numerator: # of family and CSHCN leaders trained who report increased knowledge, skill, ability and self-efficacy to serve as leaders on systems-level teams Denominator: # of CSHCN in catchment area Definitions: Family Engagement is defined as “patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system to improve health and health care.” This definition is not intended to negate the various levels or degree to which the interaction between families and professionals can take place. Family and Youth Leaders are family members who have experience navigating through service systems and are knowledgeable and skilled in partnering with professionals to carry out necessary system changes. Family members are not limited to the immediate family within the household. Meaningful [Support] Roles for family members/leaders are above and beyond “feedback” surveys. Families are considered to have a meaningful role in decision making when the partnership involves all elements of shared decision-making which are: collaboration, respect, information sharing, encouragement and consideration of preferences and values, and shared responsibility for outcomes.
BENCHMARK DATA SOURCES	Related to Healthy People 2020 Family Planning Objectives
GRANTEE DATA SOURCES	Title V National Performance Measure #2
SIGNIFICANCE	In recent years, policy makers and program administrators have emphasized the central role of family engagement in policy-making activities. In accordance with this philosophy, MCHB is facilitating such partnerships at the local, state and national levels. While there has been a significant increase in the level and types of family engagement, there is still a need to share strategies and mechanisms to recruit, train, monitor, and evaluate family engagement as a key component for CSHCN.

CSHCN 2 Performance Measure Goal: Access to and Use of Medical Home Level: Grantee Domain: CSHCN	The percent of programs promoting and/ or facilitating medical home access and use among children and youth with special health care needs.
GOAL	To ensure supportive programming medical home access and use among children and youth with special health care needs.
MEASURE	The percent of MCHB-funded projects promoting and/ or facilitating medical home access and use among children and youth with special health care needs.
DEFINITION	Tier 1: Are you promoting and/ or facilitating medical home access and use among children and youth with special health care needs? Yes No Tier 2: Through what processes/ mechanisms are you addressing medical home access and use? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of target population that demonstrate a direct linkage to a coordinated medical home community as a direct result of activities conducted by project Numerator: Target population with a demonstrated direct linkage to a coordinated medical home. Denominator: Target population (as identified in grantee application) Definitions: Medical Home: The pediatric medical home can be defined by the AAP as having the following characteristics: the medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. It should be delivered or directed by well-trained physicians who provide primary care and help to manage and facilitate essentially all aspects of pediatric care.
BENCHMARK DATA SOURCES	Objective # MICH-30.2: Increase the proportion of children with special health care needs who have access to a medical home (Baseline: 47.1% in 2005-2006, Target: 51.8%)
GRANTEE DATA SOURCES	NSCH Indicator 4.8, NSCH Indicator 4.9d, Title V National Performance Measure #3
SIGNIFICANCE	Medical homes are a cultivated partnership between patients, family, and primary care providers in coordination with support from the community. These models ensure that care must be accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective.

CSHCN 3 Performance Measure Goal: Transition Level: Grantee Domain: CSHCN	The percent of programs promoting and/or facilitating transition to adult health care for youth with special health care needs.
GOAL	To ensure supportive programming for transition to adult health care for youth with special health care needs.
MEASURE	The percent of MCHB funded projects promoting and/or facilitating transition to adult health care for youth with special health care needs.
DEFINITION	Tier 1: Are you addressing the transitional needs to adult health care for youth with special health care needs in your program? Yes No Tier 2: Through what activities are you promoting or facilitating the transition to adult health care for youth with special health care needs? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ readiness assessment # referred/ care coordinated # received direct service # participating in quality improvement initiatives (continued on next page )
DEFINITION (Continued)	Tier 4: What are the related outcomes? % of grantees promoting an evidence-informed framework and clinical recommendations for transition from pediatric to adult health care. Numerator: Number of Grantees promoting an evidence informed framework Denominator: Total Number of grantees reporting transition performance measure % of grantees involving both pediatric and adult providers/systems in transition efforts Numerator: Number of pediatric and adult providers involved in grantee transition efforts Denominator: Total number of transition practices sponsored by grantee % of grantees initiating or encouraging transition planning early in adolescence Numerator: Number of Grantees promoting transition planning early in adolescence Denominator: Total number of grantees reporting transition performance measure % of grantees linking transition efforts with medical home initiatives Numerator: Number of Grantees promoting transition as part of routine medical home care Denominator: Total number of grantees reporting transition performance measure % of grantees linking transition efforts with adolescent preventive care efforts Numerator: Number of grantees promoting transition as part of routine adolescent preventive care Denominator: Total number of grantees reporting transition performance measure Definitions: The terms “assessed for readiness” and “deemed ready” used here refer to language utilized by gottransition.org. Health care transition: is the process of changing from a pediatric to an adult model of health care. The goal of transition is to optimize health and assist youth in reaching their full potential. To achieve this goal requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in care. Transition Readiness: Assessing youth’s transition readiness and self-care skills is the third element in these health care transition quality recommendations. Use of a standardized transition assessment tool is helpful in engaging youth and families in setting health priorities; addressing self-care needs to prepare them for an adult approach to care at age 18, and navigating the adult health care system, including health insurance. Providers can use the results to jointly develop a plan of care with youth and families. Transition readiness assessment should begin at age 14 and continue through adolescence and young adulthood, as needed.
BENCHMARK DATA SOURCES	NA
GRANTEE DATA SOURCES	Title V National Performance Measure #6 and #12, NS-CSHCN Survey Outcome #6
SIGNIFICANCE	Transitioning of children to adolescent services to adult services is important to ensure that growth and development is adequately and accurately screened throughout all stages. These stages of life represent a time of rapid development and it is important to make sure changes are documented and children and receiving appropriate treatment, preventive services, and screenings.

AH 1 Performance Measure Goal: Adolescent Well Visit Level: Grantee Domain: Adolescent Health	The percent of programs promoting and/ or facilitating adolescent well visits.
GOAL	To ensure supportive programming for adolescent well visits.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating adolescent well visits.
DEFINITION	Tier 1: Are you promoting and/ or facilitating adolescent well visits in your program? Yes No Tier 2: Through what processes/ mechanisms are you promoting and/ or facilitating adolescent well visits? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? (Report in Table 1: Activity Data Collection Form) # receiving TA # receiving training # products developed # peer-reviewed publications published # receiving information and education through outreach # receiving screening/ assessment training # referred/care coordinated # received direct service # participating in quality improvement initiatives Tier 4: What are the related outcomes? % of adolescents with an adolescent well visit in the past year Numerator: Adolescents reached by the program in reporting year who had an adolescent well visit during the reporting period. Denominator: Adolescents reached by the program in reporting year % of adolescents enrolled in Medicaid/ CHIP with at least one adolescent well visit in the past year Numerator: Adolescents enrolled in Medicaid/ CHIP reached by the program in reporting year with at least one adolescent well visit in the reporting year Denominator: Adolescents enrolled in Medicaid/ CHIP reached by the program in reporting year. Age range of adolescents served: ________________________
BENCHMARK DATA SOURCES	Related to Adolescent Health Objective 1: Increase the proportion of adolescent who have had a wellness checkup in the past 12 months Baseline: 68.7%, Target: 75.6%).
GRANTEE DATA SOURCES	Title V National Performance Measure 10, Adolescent Health (AH), National Vital Statistics System (NVSS) Birth File, Home Visiting
SIGNIFICANCE	Adolescence is an important period of development physically, psychologically, and socially. As adolescents move from childhood to adulthood, they are responsible for their health including annual preventive well visits which help to maintain a healthy lifestyle, avoid damaging behaviors, manage chronic conditions, and prevent disease.

AH 2 Performance Measure Goal: Injury Prevention Level: Grantee Domain: Adolescent Health	The percent of programs promoting and/ or facilitating adolescent injury prevention.
GOAL	To ensure supportive programming for adolescent injury prevention.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating injury prevention and through what processes.
DEFINITION	Tier 1: Are you promoting and/ or facilitating injury prevention in your program? Yes No Tier 2: Through what processes/ mechanisms are you promoting and/ or facilitating injury-prevention? See data collection form. Technical Assistance Training Research/ dissemination Peer-reviewed publications Outreach/ Information Dissemination/ Education Referral/ care coordination Quality improvement initiatives Use of fatality review data Please check which child safety domains which program activities were designed to impact: Motor Vehicle Traffic Suicide/ Self-Harm Falls Bullying Youth Violence (other than bullying) Child Maltreatment Unintentional Poisoning Prescription drug overdose Traumatic Brain Injury Drowning Other Tier 3: How many are reached through those activities? # receiving TA # receiving professional/organizational development training # of peer-reviewed publications published # receiving information and education through outreach # referred/ managed % using fatality review data See data collection form. Tier 4: What are the related outcomes? Rate of injury-related hospitalization to children ages 10-19. Numerator: # of injury-related hospitalizations to children ages 10-19 Denominator: # of children ages 10-19 in the target population Target Population:___________________________ Percent of children ages 12-17 missing 11 or more days of school because of illness or injury. Numerator: # of children ages 12-17 missing 11 or more days of school Denominator: Total number of children ages 12-17 represented in National Survey of Children’s Health result Dataset used: _______________________________
BENCHMARK DATA SOURCES	Related to Healthy People Injury and Violence Prevention objectives 1 through 39.
GRANTEE DATA SOURCES	AHRQ Healthcare Cost and Utilization Project: National Inpatient Sample or State Inpatient Database National Survey of Children’s Health, 6-11 year old survey, Question G1
SIGNIFICANCE	Two dozen children die every day in the United States from an unintentional or intentional injury. In addition, millions of children survive their injury and have to live the rest of their lives with negative health effects. Although there has been much progress in the United States in reducing child injuries, more is needed.

Data Collection Form for Detail Sheet # AH 2

Please use the form below to report what services you provided in which safety domains, and how many received those services. Please use the space provided for notes to specify the recipients of each type of service.

	Motor Vehicle Traffic	Suicide / Self-Harm	Falls	Bullying	Youth Violence (other than bullying)	Child Maltreatment	Unintentional Poisoning	Prescription drug overdose	Traumatic Brain Injury	Drowning	Other (Specify)
Technical Assistance
Training
Research/ dissemination
Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Referral/ care coordination
Quality improvement initiatives
Use of fatality review data
Notes:

AH 3 Performance Measure Goal: Screening for Major Depressive Disorder Level: Grantee Domain: Adolescent Health	The percent of programs promoting and/ or facilitating screening for major depressive disorder.
GOAL	To ensure supportive programming for screening for major depressive disorder.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating screening for major depressive disorder for adolescents and through what processes.
	Tier 1: Are you promoting and/ or facilitating screening major depressive disorder for adolescents in your program? Yes No Tier 2: Through what processes/ mechanisms are you addressing injury prevention? Technical Assistance Training Research/ dissemination Peer-reviewed publications Outreach/ Information Dissemination/ Education Referral/ care coordination Quality improvement initiatives Use of fatality review data Tier 3: How many are reached through those activities? # receiving TA # receiving professional/organizational development training # products disseminated # peer-reviewed publications published # receiving information and education through outreach # referred/ managed % using fatality review data
DEFINITION	Tier 4: What are the related outcomes? % of 12-17 year olds screened for MDD in the past year in community level or school health settings Numerator: Adolescents involved with your program in the reporting year who were screened for MDD in a community-level or school health setting. Denominator: Adolescents involved with your program in the reporting year. % of adolescent well care visits that include screening for MDD Numerator: Adolescents involved with your program in the reporting year that had a well-child that included a screening for MDD, in the reporting year. Denominator: Adolescents involved with your program in the reporting year that had a well-child visit in the reporting year. % of adolescents identified with a MDD that receive treatment Numerator: Adolescents involved with your program identified as having an MDD that received treatment during the reporting year Denominator: Adolescents involved with your program during the reporting year identified as having an MDD % of adolescents with a MDD Numerator: Adolescents involved with your program during the reporting year identified as having an MDD Denominator: Adolescents involved with your program in the reporting year. Age range of adolescents served: ________________________
BENCHMARK DATA SOURCES	Healthy People 2020, MHMD 11.2 – Increase the proportion of primary care physician office visits where youth aged 12 to 18 years are screened for depression (Baseline 2.1 in 2007, Target: 2.3%); Healthy People 2020 Objective MHMD-4.1. Percent of adolescents aged 12 to 17 years experienced a major depressive episode (Baseline: 8.3% in 2008, Target: 7.5%)
GRANTEE DATA SOURCES
SIGNIFICANCE	Major depression is becoming more and more common in the United States. Major depression entails interference with the ability to work, sleep, study, eat, and enjoy life. Screening for this disorder can identify individuals and effectively treat them.

LC 1 Performance Measure Goal: Adequate Health Insurance Coverage Level: Grantee Domain: Life Course/ Cross Cutting	The percent of programs promoting and/ or facilitating adequate health insurance coverage.
GOAL	To ensure supportive programming for adequate health insurance coverage.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating adequate health insurance coverage.
DEFINITION	Tier 1: Are you promoting and/ or facilitating adequate health insurance coverage in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating adequate health insurance coverage? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral to insurance enrollment Quality improvement initiatives Tier 3: How many are reached through those activities? See data LC 1 Data Collection Form. Tier 4: What are the related outcomes? % with health insurance Numerator: Program participants with health insurance during the reporting period Denominator: Program participants during the reporting period A participant is considered to have insurance if they have any kind of health insurance that covers medical care, including prepaid plans such as HMOs, government plans such as Medicaid, and private coverage including coverage purchased through the Health Care Marketplace. % with adequate health insurance in the reporting year Numerator: Program participants who reported having adequate insurance coverage during the reporting period Denominator: Program participants during the reporting period
BENCHMARK DATA SOURCES	Related to HP2020 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%)
GRANTEE DATA SOURCES	Title V National Performance Measure #15, Title V National Outcome Measure #21
SIGNIFICANCE	Individuals 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 prescription drugs, appropriate care for asthma and basic dental services. 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.

Data Collection form for #LC 1

Please check all population domains that you engage in each activity listed in Tier 2 related to adequate Health Insurance Coverage. For those activities or population domains that do not pertain to you, please leave them blank.

	Pregnant/ Perinatal Women	Infants	Children	CSHCN	Adolescents	Non-pregnant Adults	Partners/ Other Organizations	Providers	Other
Technical Assistance
Training
Product Development
Research/ Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Tracking/ Surveillance
Screening/ Assessment
Referral
Direct Service
Quality improvement initiatives

LC 2 Performance Measure Goal: Tobacco and eCigarette Use Level: Grantee Domain: Life Course/ Cross Cutting	The percent of programs promoting and/ or facilitating tobacco and eCigarette cessation.
GOAL	To ensure supportive programming promoting and/ or facilitating tobacco and eCigarette cessation.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating tobacco and eCigarette cessation, and through what processes.
DEFINITION	Tier 1: Are you addressing tobacco and eCigarette cessation in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating tobacco and eCigarette cessation? Technical Assistance Training Product Development Research/ Peer-reviewed publications Outreach/ Information Dissemination/ Education Tracking/ Surveillance Screening/ Assessment Referral/ care coordination Direct Service Quality improvement initiatives Tier 3: How many are reached through those activities? See data LC 2 Data Collection Form. Tier 4: What are the related outcomes? % of prenatal women who abstain from smoking during pregnancy Numerator: Number of program prenatal participants who abstained from smoking cigarettes (including all tobacco products and e-cigarettes) for their entire pregnancy. Denominator: Number of program prenatal participants. % of prenatal women who stopped smoking during pregnancy Numerator: Number of program participants who stopped smoking cigarettes (including all tobacco products and e-cigarettes) during their pregnancy. Denominator: Number of program prenatal participants who smoked at the beginning of their pregnancy.
BENCHMARK DATA SOURCES	Related to Tobacco Use Objective 6: Increase smoking cessation during pregnancy (Target: 30.0%) and related to Tobacco Use Objective 11.1L Reduce to proportion of children aged 3 to 11 years exposed to secondhand smoke (Baseline: 52.2%, Target: 47%).
GRANTEE DATA SOURCES	Title V National Performance Measure #14, NSCH 12-13
SIGNIFICANCE	Secondhand smoke is a mixture of mainstream smoke and the more toxic side stream smoke which is classified as a “known human carcinogen” by the US Environmental Protection Agency, the US National Toxicology Program, and the International Agency for Research on Cancer. In addition, women who smoke during pregnancy are more likely to experience a fetal death or deliver a low birth weight baby.

Data Collection form for #LC 2

Please check all population domains that you engage in each activity listed in Tier 2 related to tobacco cessation. For those activities or population domains that do not pertain to you, please leave them blank.

	Pregnant/ Perinatal Women	Infants	Children	CSHCN	Adolescents	Non-pregnant Adults	Partners/ Other Organizations	Providers	Other
Technical Assistance
Training
Product Development
Research/ Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Tracking/ Surveillance
Screening/ Assessment
Referral
Direct Service
Quality improvement initiatives

LC 3 Performance Measure Goal: Oral Health Level: Grantee Domain: Life Course/ Cross Cutting	The percent of programs promoting and/ or facilitating oral health.
GOAL	To ensure supportive programming for oral health.
MEASURE	The percent of MCHB funded projects promoting and/ or facilitating oral health, and through what activities.
DEFINITION	Tier 1: Are you promoting and/ or facilitating oral health in your program? Yes No Tier 2: Through what activities are you promoting and/ or facilitating oral health? Technical Assistance MCH Workforce Development Community Outreach Care coordination / Referral Provision of services Research/ Peer-reviewed publication Tier 3: How many from each population are reached through each of the activities? See data LC 3 Data Collection Form. Tier 4: What are the related outcomes? % of program participants receiving an oral health risk assessment Numerator: Number of program participants who received an oral health risk assessment in the reporting year Denominator: All program participants % of women in program population who had a dental visit during pregnancy Numerator: Program participants who were pregnant during the reporting year who had a dental visit Denominator: Program participants who were pregnant during the reporting year % of those aged 1 through 17 who had preventative oral health visit during the last year Numerator: Infants and children involved with the program who received a preventative oral health visit in the reporting year Denominator: Infants and children involved with the program during the reporting year.
BENCHMARK DATA SOURCES	Related to Oral Health Objective 7: Increase the proportion of children, adolescents, and adults who used the oral health care system in the past year (Baseline: 30.2%, Target: 49.0%). Related to Oral Health Objective 8: Increase the proportion of low-income children and adolescents who receive any preventive dental service during the past year (Baseline: 30.2%, Target: 33.2%).
GRANTEE DATA SOURCES	Title V National Performance Measure #13
SIGNIFICANCE	Oral health is a vital component of overall health. Access to oral health care, good oral hygiene and adequate nutrition are essential components of oral health to help ensure individuals achieve and maintain oral health. Those with limited preventive oral health services access are at a greater risk for oral diseases.

Data Collection Form for #LC 3

Please use the form below to identify what services you provide to each population. For those that you provide the service to, please provide the number of services provided (i.e. number of children receiving referrals), for those that you do not, please leave blank.

	Pregnant/ Perinatal Women	Infants	Children	CSHCN	Adolescents	Non-pregnant Adults	Partners/ Other Organizations	Providers	Other
Technical Assistance
Training
Product Development
Research/ Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Tracking/ Surveillance
Screening/ Assessment
Referral
Direct Service
Quality improvement initiatives

DIVISION OF MCH WORKFORCE DEVELOPMENT:

PERFORMANCE MEASURE DETAIL SHEET SUMMARY TABLE

Performance Measure	New/Revised Measure	Prior PM Number (if applicable)	Topic
Training 01	New	N/A	MCH Training Program and Healthy Tomorrows Family Member/Youth/Community Member participation
Training 02	New	N/A	MCH Training Program and Healthy Tomorrows Cultural Competence
Training 03	New	N/A	Healthy Tomorrows Title V Collaboration
Training 04	Revised	59	Title V Collaboration
Training 05	Revised	85	Policy
Training 06	Revised	09	Diversity of Long-Term Trainees
Training 07	New	N/A	MCH Pipeline Program – Work with MCH populations
Training 08	New	N/A	MCH Pipeline Program – Work with underserved or vulnerable populations
Training 09	Revised	83	MCH Pipeline - Graduate Program Enrollment
Training 10	Revised	08	Leadership
Training 11	Revised	84	Work with MCH Populations
Training 12	Revised	60	Interdisciplinary Practice
Training 13	No changes	64	Diverse Adolescent Involvement (LEAH-specific)
Training 14	Revised	86	Medium-Term Trainees Skill and Knowledge (PPC-Specific)

Training 01 PERFORMANCE MEASURE Goal: Family/ Youth/ Community Engagement in MCH Training and Healthy Tomorrows Programs Level: Grantee Domain: MCH Workforce Development	The percent of MCHB training and Healthy Tomorrows programs that ensure family, youth, and community member participation in program and policy activities.
GOAL	To increase family, youth, and/or community member participation in MCH Training and Healthy Tomorrows programs.
MEASURE	The percent of MCHB training and Healthy Tomorrows programs that ensure family/ youth/ community member participation in program and policy activities.
DEFINITION	Attached is a table of five elements that demonstrate family member/youth/community member participation, including an emphasis on partnerships and building leadership opportunities for family members/youth/community members in MCH Training or Healthy Tomorrows programs. Please check yes or no to indicate if your MCH Training Program or Healthy Tomorrows program has met each element.
BENCHMARK DATA SOURCES	PHI-3: Increase the proportion of Council on Education for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs, and schools of nursing (with a public health or community health component) that integrate Core Competencies for Public Health Professionals into curricula
GRANTEE DATA SOURCES	Attached data collection form to be completed by grantee.
SIGNIFICANCE	Over the last decade, policy makers and program administrators have emphasized the central role of families and other community members as advisors and participants in program and policy-making activities. In accordance with this philosophy, MCH Training Programs and Healthy Tomorrows Programs are facilitating such partnerships at the local, State and national levels. MCH Training programs support interdisciplinary/interprofessional graduate education and training programs that emphasize leadership, and family-centered, community-based, and culturally competent systems of care. Training programs are required to incorporate family members/youth/community members as faculty, trainees, and partners. The Healthy Tomorrows program supports community initiated and community-based projects that apply principles of health promotion, disease prevention, and the benefits of coordinated health care to the provision of services that improve access to comprehensive, community-based, family-centered, culturally/linguistically competent, and coordinated care. Healthy Tomorrows projects are required to incorporate family members/youth/community members as project staff, advisors, volunteers, and partners.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 01 - Family/ Youth/ Community Engagement in MCH Training and Healthy Tomorrows Programs

Please indicate if your MCH Training or Healthy Tomorrows program has included family members, youth, and/or community members in each of the program elements listed below. Use the space provided for notes to provide additional details about activities, as necessary. (NOTE: Programs are only required to have participation from family members or youth or community members for each element to answer “Yes”)

Element	No	Yes
Participatory Planning Family members/youth/community members participate in and provide feedback on the planning, implementation and/or evaluation of the training or Healthy Tomorrows program’s activities (e.g. strategic planning, program planning, materials development, program activities, and performance measure reporting).
Cultural Diversity Culturally diverse family members/youth/community members facilitate the training or Healthy Tomorrows program’s ability to meet the needs of the populations served.
Leadership Opportunities Within your training or Healthy Tomorrows program, family members/youth/community members are offered training, mentoring, and/or opportunities for leadership roles on advisory committees or task forces.
Compensation Family members/youth/community members who participate in the MCH Training or Healthy Tomorrows program are paid faculty, staff, consultants, or compensated for their time and expenses.
Train MCH/CSHCN staff Family members/youth/community members work with their training or Healthy Tomorrows program to provide training (pre‑service, in-service and professional development) to MCH/CSHCN faculty/staff, students/trainees, and/or providers.

NOTES/COMMENTS:

Training 02 PERFORMANCE MEASURE Goal: Cultural Competence in MCH Training and Healthy Tomorrows Programs Level: Grantee Domain: MCH Workforce Development	The percent of MCHB training and Healthy Tomorrows programs that have incorporated cultural and linguistic competence elements into their policies, guidelines, and training.
GOAL	To increase the percentage of MCH Training and Healthy Tomorrows programs that have integrated cultural and linguistic competence into their policies, guidelines, and training.
MEASURE	The percent of MCHB training and Healthy Tomorrows programs that have integrated cultural and linguistic competence into their policies, guidelines, and training.
DEFINITIONS	Attached is a checklist of 6 elements that demonstrate cultural and linguistic competency. Please check yes or no to indicate if your MCH Training or Healthy Tomorrows program has met each element. Please keep the completed checklist attached. Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals th­­at enables effective work in cross-cultural situations. ‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. ‘Competence’ implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989; cited from National Center for Cultural Competence (http://nccc.georgeto wn.edu/foundations/frameworks.html)
DEFINITIONS (cont…)	Linguistic competence is 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 have low literacy skills or are not literate, and individuals with disabilities. Linguistic competency requires organizational and provider capacity to respond effectively to the health literacy needs of populations served. The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity. (Goode, T. and W. Jones, 2004. National Center for Cultural Competence; http://www.nccccurricula.info/linguisticcompetence.html) Cultural and linguistic competency is a process that occurs along a developmental continuum. A culturally and linguistically competent program is characterized by elements including the following: written strategies for advancing cultural competence; cultural and linguistic competency policies and practices; cultural and linguistic competence knowledge and skills building efforts; research data on populations served according to racial, ethnic, and linguistic groupings; faculty and other instructors are racially and ethnically diverse; faculty and staff participate in professional development activities related to cultural and linguistic competence; and periodic assessment of trainees’ progress in developing cultural and linguistic competence.
BENCHMARK DATA SOURCES	Related to the following HP2020 Objectives: PHI-3: Increase the proportion of Council on Education for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs, and schools of nursing (with a public health or community health component) that integrate Core Competencies for Public Health Professionals into curricula PHI-12: Increase the proportion of public health laboratory systems (including State, Tribal, and local) which perform at a high level of quality in support of the 10 Essential Public Health Services ECBP-11: Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs
GRANTEE DATA SOURCES	Attached data collection form is to be completed by grantees. There is no existing national data source to measure the extent to which MCHB supported programs have incorporated cultural competence elements into their policies, guidelines, and training.
SIGNIFICANCE	Over the last decade, researchers and policymakers have emphasized the central influence of cultural values and cultural/linguistic barriers: health seeking behavior, access to care, and racial and ethnic disparities. In accordance with these concerns, cultural competence objectives have been: (1) incorporated into the Division of MCH Workforce Development strategic plan; and (2) in guidance materials related to the MCH Training and Healthy Tomorrows Programs. The Division of MCH Workforce Development provides support to programs that address cultural and linguistic competence through development of curricula, research, learning and practice environments

DATA COLLECTION FORM FOR DETAIL SHEET: Training 02 – Cultural Competence in MCH Training and Healthy Tomorrows Programs

Please indicate if your MCH Training or Healthy Tomorrows program has incorporated the following cultural/linguistic competence elements into your policies, guidelines, and training.

Please use the space provided for notes to provide additional details about the elements, as applicable.

Element	Yes 1	No 0
Written Guidelines Strategies for advancing cultural and linguistic competency are integrated into your training or Healthy Tomorrows program’s written plan(s) (e.g., grant application, recruiting plan, placement procedures, monitoring and evaluation plan, human resources, formal agreements, etc.).
Training Cultural and linguistic competence knowledge and skills building are included in training aspects of your program.
Data Research or program information gathering includes the collection and analysis of data on populations served according to racial, ethnic, and linguistic groupings, where appropriate.
Staff/faculty diversity MCH Training Program or Healthy Tomorrows staff and faculty reflect cultural and linguistic diversity of the significant populations served.
Professional development MCH Training Program or Healthy Tomorrows staff and faculty participate in professional development activities to promote their cultural and linguistic competence.
Measure progress Measurement of Progress A process is in place to assess the progress of MCH Training program or Healthy Tomorrows participants in developing cultural and linguistic competence.

NOTES/COMMENTS:

Training 03 PERFORMANCE MEASURE Goal: Healthy Tomorrow’s Partnership Level: Grantee Domain: MCH Workforce Development	The degree to which the Healthy Tomorrows Partnership for Children program collaborates with State Title V agencies, other MCH or MCH-related programs.
GOAL	To assure that the Healthy Tomorrows program has collaborative interactions related to professional development, policy development and product development and dissemination with relevant national, state and local MCH programs, agencies and organizations.
MEASURE	The degree to which a Healthy Tomorrows program collaborates with State Title V agencies, other MCH or MCH-related programs and other professional organizations.
DEFINITION	Attached is a list of the 7 elements that describe activities carried out by Healthy Tomorrows programs for or in collaboration with State Title V and other agencies on a scale of 0 to 1 (0=no; 1=yes). If a value of ‘1’ (yes) is selected, provide the number of activities for the element. The total score for this measure will be determined by the sum of those elements noted as ‘1.’
BENCHMARK DATA SOURCES	ECBP-11(Developmental) Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs … ECPB-2: Increase the proportion of elementary, middle, junior high, and senior high schools that provide comprehensive school health education to prevent health problems. ECBP-12 Increase the inclusion of core clinical prevention and population health content in M.D.-granting medical schools. ECBP-13: Increase the inclusion of core clinical prevention and population health content in in D.O.-granting medical schools. ECBP-15: Increase the inclusion of core clinical prevention and population health content in in nurse practitioner training. ECBP-17: Increase the inclusion of core clinical prevention and population health content in in Doctor of Pharmacy (PharmD) granting colleges and schools of pharmacy PHI-2(Developmental) Increase the proportion of Tribal, State, and local public health personnel who receive continuing education consistent with the Core Competencies for Public Health Professionals
GRANTEE DATA SOURCES	The Healthy Tomorrows program completes the attached table which describes the categories of collaborative activity.
SIGNIFICANCE	As a SPRANS grantee, a training program enhances the Title V State block grants that support the MCHB goal to promote comprehensive, coordinated, family-centered, and culturally-sensitive systems of health care that serve the diverse needs of all families within their own communities. Interactive collaboration between a training program and Federal, Tribal, State and local agencies dedicated to improving the health of MCH populations will increase active involvement of many disciplines across public and private sectors and increase the likelihood of success in meeting the goals of relevant stakeholders. This measure will document a Healthy Tomorrows program’s abilities to: collaborate with State Title V and other agencies (at a systems level) to support achievement of the MCHB Strategic Goals and Healthy People 2020 action plan; make the needs of MCH populations more visible to decision-makers and can help states achieve best practice standards for their systems of care; internally use this data to assure a full scope of these program elements in all regions.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 03 – Healthy Tomorrows Partnership

Indicate the degree to which the Healthy Tomorrows program collaborates with State Title V (MCH Block Grant) agencies and other MCH-related programs* using the following values:

0= Does not collaborate on this element 1= Does collaborate on this element.

If your program does collaborate, provide the total number of activities for the element.

	State Title V Agencies1			Other MCH-related programs2
Element	0	1	Total number of activities	0	1	Total number of activities
Advisory Committee Examples might include: having representation from State Title V or other MCH program on your advisory committee
Professional Development & Training Examples might include: collaborating with state Title V agency to develop state training activity
Policy Development Examples might include: working with State Title V agency to develop and pass legislation
Research, Evaluation, and Quality Improvement Examples might include: working with MCH partners on quality improvement efforts
Product Development Examples might include: participating on collaborative with MCH partners to develop community materials
Dissemination Examples might include: disseminating information on program implementation to local MCH partners
Sustainability Examples might include: working with state and local MCH representatives to develop sustainability plans
Total

¹State Title V programs include State Block Grant funded or supported activities.

²Other maternal and child health-related programs (both MCHB-funded and funded from other sources) include, but are not limited to:

• State Health Department

• State Adolescent Health

• Social Service Agency

• Medicaid Agency

• Education

• Juvenile Justice

• Early Intervention

• Home Visiting

• Professional Organizations/Associations

• Family and/or Consumer Group

• Foundations

• Clinical Program/Hospitals

• Local and state division of mental health

• Developmental disability agencies

• Other programs working with maternal and child health populations

Training 04 PERFORMANCE MEASURE Goal: Collaborative Interactions Level: Grantee Domain: MCH Workforce Development	The degree to which a training program collaborates with State Title V agencies, other MCH or MCH-related programs.
GOAL	To assure that a training program has collaborative interactions related to training, technical assistance, continuing education, and other capacity-building services with relevant national, state and local programs, agencies and organizations.
MEASURE	The degree to which a training program collaborates with State Title V agencies, other MCH or MCH-related programs and other professional organizations.
DEFINITION	Attached is a list of the 6 elements that describe activities carried out by training programs for or in collaboration with State Title V and other agencies on a scale of 0 to 1. If a value of ‘1’ is selected, provide the number of activities for the element. The total score for this measure will be determined by the sum of those elements noted as ‘1.’
BENCHMARK DATA SOURCES	ECBP-11(Developmental) Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs. ECPB-2: Increase the proportion of elementary, middle, junior high, and senior high schools that provide comprehensive school health education to prevent health problems. ECBP-12 Increase the inclusion of core clinical prevention and population health content in M.D.-granting medical schools. ECBP-13: Increase the inclusion of core clinical prevention and population health content in in D.O.-granting medical schools. ECBP-15: Increase the inclusion of core clinical prevention and population health content in in nurse practitioner training. ECBP-17: Increase the inclusion of core clinical prevention and population health content in in Doctor of Pharmacy (PharmD) granting colleges and schools of pharmacy PHI-2(Developmental) Increase the proportion of Tribal, State, and local public health personnel who receive continuing education consistent with the Core Competencies for Public Health Professionals
GRANTEE DATA SOURCES	The training program completes the attached table which describes the categories of collaborative activity.
SIGNIFICANCE	As a SPRANS grantee, a training program enhances the Title V State block grants that support the MCHB goal to promote comprehensive, coordinated, family-centered, and culturally-sensitive systems of health care that serve the diverse needs of all families within their own communities. Interactive collaboration between a training program and Federal, Tribal, State and local agencies dedicated to improving the health of MCH populations will increase active involvement of many disciplines across public and private sectors and increase the likelihood of success in meeting the goals of relevant stakeholders. This measure will document a training program’s abilities to: collaborate with State Title V and other agencies (at a systems level) to support achievement of MCHB Strategic Goals; make the needs of MCH populations more visible to decision-makers and can help states achieve best practice standards for their systems of care; and internally use this data to assure a full scope of these program elements in all regions.

DATA COLLECTION FORM FOR DETAIL SHEET PM #Training 04 – Collaborative Interactions

Indicate the degree to which your training program collaborates with State Title V (MCH Block Grant) agencies and other MCH-related programs* using the following values:

0= Does not collaborate on this element 1= Does collaborate on this element.

If your program does collaborate, provide the total number of activities for the element.

Element	State Title V programs1			Other MCH-related programs2
	0	1	Total number of activities	0	1	Total number of activities
Service* Examples might include: Clinics run by the training program and/ or in collaboration with other agencies
Training Examples might include: Training in Bright Futures; Workshops related to adolescent health practice; and Community-based practices. It would not include clinical supervision of long-term trainees.
Continuing Education Examples might include: Conferences; Distance learning; and Computer-based educational experiences. It would not include formal classes or seminars for long-term trainees.
Technical Assistance Examples might include: Conducting needs assessments with State programs; policy development; grant writing assistance; identifying best-practices; and leading collaborative groups. It would not include conducting needs assessments of consumers of the training program services.
Product Development Examples might include: Collaborative development of journal articles and training or informational videos.
Research Examples might include: Collaborative submission of research grants, research teams that include Title V or other MCH-program staff and the training program’s faculty.
Total

¹State Title V programs include State Block Grant funded or supported activities.

²Other maternal and child health-related programs (both MCHB-funded and funded from other sources) include, but are not limited to:

• State Health Department

• State Adolescent Health

• Social Service Agency

• Medicaid Agency

• Education

• Juvenile Justice

• Early Intervention

• Home Visiting

• Professional Organizations/Associations

• Family and/or Consumer Group

• Foundations

• Clinical Program/Hospitals

• Local and state division of mental health

• Developmental disability agencies

• Other programs working with maternal and child health populations

*Ongoing collaborations with clinical locations should be counted as one activity (For example: multiple trainees rotate through the same community-based clinical site over the course of the year. This should be counted as one activity.)

Training 05 PERFORMANCE MEASURE Goal: Policy Development Level: Grantee Domain: MCH Workforce Development	The degree to which MCH long-term training grantees engage in policy development, implementation, and evaluation.
GOAL	To increase the number of MCH long-term training programs that actively promote the transfer and utilization of MCH knowledge and research to the policy arena through the work of faculty, trainees, alumni, and collaboration with Title V.
MEASURE	The degree to which MCH long-term training grantees engage in policy development, implementation, and evaluation.
DEFINITION	Attached is a list of six elements that demonstrate policy engagement. Please check yes or no to indicate which the elements have been implemented. Please keep the completed checklist attached. Policy development, implementation and evaluation in the context of MCH training programs relates to the process of translating research to policy and training for leadership in the core public health function of policy development. Actively – mutual commitment to policy-related projects or objectives within the past 12 months.
BENCHMARK DATA SOURCES	Related to PHI-3: Increase the proportion of Council on Education for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs, and schools of nursing (with a public health or community health component) that integrate Core Competencies for Public Health Professionals into curricula.
GRANTEE DATA SOURCES	• Attached data collection form to be completed by grantee. • Data will be collected from competitive and continuation applications as part of the grant application process and annual reports. The elements of training program engagement in policy development, implementation, and evaluation need to be operationally defined with progress noted on the attached list with an example described more fully in the narrative application.
SIGNIFICANCE	Policy development is one of the three core functions of public health as defined by the Institute of Medicine in The Future of Public Health (National Academy Press, Washington DC). In this landmark report by the IOM, the committee recommends that “every public health agency exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy.” Academic institutions such as schools of public health and research universities have the dual responsibility to develop knowledge and to produce well-trained professional practitioners. This national performance measure relates directly to Goal 4 of the Division of MCH Workforce Development Strategic Plan to “generate and translate new knowledge for the MCH field in order to advance science-based practice, innovation, and quality improvement in MCH training, policies and programs.”

DATA COLLECTION FORM FOR DETAIL SHEET: Training 05 - Policy Development

Using a response of Yes (1) or No (0), indicate whether your training program has addressed the following policy training and policy participation elements.

CATEGORY #1: Training on Policy and Advocacy

Element	No 0	Yes 1
Your MCHB-funded Training Program provides didactic opportunities for training on policy development and advocacy to increase understanding of how the policy process works at the federal, state and/or local levels.
Your MCHB-funded Training Program provides an opportunity for application of policy and advocacy knowledge through one or more of the following educational experiences If Yes, check all that apply: Write a policy brief about an emerging local MCH public health issue Attend a meeting of a local MCH stakeholder group, provide a written summary of their approach Attend a professional association meeting and actively participate on a committee Educate Policymakers Provide written and/or oral testimony to the state legislature Write an article on an MCH topic for a lay audience Observe a legislative hearing on CSPAN, or if possible, attend a legislative hearing on an MCH topic Track a bill over the Internet over the course of a legislative session Interview an agency or organization-based MCH policy maker, administrator, or advocate and prepare written and/or oral mock testimony from the perspective of the agency/association interviewed Other, please describe ________________________
A pre/post assessment is in place to measure increased policy knowledge and skills of long-term trainees (NOTE: Long-term trainees are defined as those who have completed a long-term [greater than or equal to 300 contact hours] MCH Training Program, including those who received funds and those who did not). If Yes, report: % of current trainees reporting increased policy knowledge _____________ % of current trainees reporting increased policy skills ________________

CATEGORY #2: Participation in Policy Change and Translation of Research into Policy

Element	No 0	Yes 1
Trainees, faculty and/or staff contribute to the development of guidelines, regulation, legislation or other public policy at the local, state, and/or national level. If yes, indicate all policy arenas to which they have contributed: Local State National
Trainees, faculty and/or staff participate in local, state and/or national MCH advocacy networks and initiatives If yes, indicate all policy arenas to which they have contributed : Local State National
Trainees, faculty and/or staff participate in disseminating and communicating research findings (both original and non-original) directly to public health agency leaders and/or policy officials. If yes, indicate all policy arenas to which they have contributed: Local State National

Training 06 Performance Measure Goal: Long Term Training Programs Level: Grantee Domain: MCH Workforce Development	The percentage of participants in MCHB long-term training programs who are from underrepresented racial and ethnic groups.
GOAL	To increase the percentage of trainees participating in MCHB long‑term training programs who are from underrepresented racial and ethnic groups.
MEASURE	The percentage of participants in MCHB long-term training programs who are from underrepresented racial and ethnic groups.
DEFINITION	Numerator: Total number of long‑term trainees (≥ 300 contact hours) participating in MCHB training programs reported to be from underrepresented racial and ethnic groups. (Include MCHB-supported and non-supported trainees.) Denominator: Total number of long‑term trainees (≥ 300 contact hours) participating in MCHB training programs. (Include MCHB-supported and non-supported trainees.) Units: 100 Text: Percentage The definition of “underrepresented racial and ethnic groups” is based on the categories from the U.S. Census.
BENCHMARK DATA SOURCES	Related to Healthy People 2020 Objectives: AHS-4: Increase the number of practicing primary care providers ECBP-11: (Developmental) Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs
GRANTEE DATA SOURCES	Data will be collected annually from grantees about their trainees. MCHB does not maintain a master list of all trainees who are supported by MCHB long‑term training programs. References supporting Workforce Diversity:  In the Nation’s Compelling Interest: Ensuring Diversity in the Healthcare Workforce (2004). Institute of Medicine.  Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002). Institute of Medicine.
SIGNIFICANCE	HRSA’s MCHB places special emphasis on improving service delivery to women, children and youth from communities with limited access to comprehensive care. Training a diverse group of professionals is necessary in order to provide a diverse public health workforce to meet the needs of the changing demographics of the U.S. and to ensure access to culturally competent and effective services. This performance measure provides the necessary data to report on HRSA’s initiatives to reduce health disparities.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 06 – Long Term Training Programs

Report on the percentage of long-term trainees (≥300 contact hours) who are from any underrepresented racial/ethnic group (i.e., Hispanic or Latino, American Indian or Alaskan Native, Asian, Black or African-American, Native Hawaiian or Pacific Islander, two or more race (OMB). Please use the space provided for notes to detail the data source and year of data used.

• Report on all long-term trainees (≥ 300 contact hours) including MCHB-funded and non MCHB-funded trainees

• Report race and ethnicity separately

• Trainees who select multiple ethnicities should be counted once

• Grantee reported numerators and denominator will be used to calculate percentages

Total number of long term trainees (≥ 300 contact hours) participating in the training program. (Include MCHB-supported and non-supported trainees.)

________

Ethnic Categories

Number of long-term trainees who are Hispanic or Latino (Ethnicity) ________

Racial Categories

Number of long-term trainees who are American Indian or Alaskan Native ________

Number of long-term trainees who are of Asian descent ________

Number of long-term trainees who are Black or African-American ________

Number of long-term trainees who are Native Hawaiian or Pacific Islanders ________

Number of long-term trainees who are two or more races ________

Notes/Comments:

Training 07 PERFORMANCE MEASURE Goal: MCH Pipeline Programs Level: Grantee Domain: MCH Workforce Development	The percent of MCHB Pipeline Program graduates who have been engaged in work focused on MCH populations.
GOAL	To increase the percent of graduates of MCH Pipeline Programs who have been/are engaged in work focused on MCH populations.
MEASURE	The percent of MCHB Pipeline Program graduates who have been engaged in work focused on MCH populations since graduating from the MCH Pipeline Training Program.
DEFINITION	Numerator: Number of pipeline graduates reporting they have been engaged in work focused on MCH populations since graduating from the MCH Pipeline Training Program. Denominator: The total number of trainees responding to the survey Units: 100 Text: Percent MCH Pipeline trainees are defined as undergraduate students from economically and educationally disadvantaged backgrounds (including underrepresented racial and ethnic minorities: African American, Hispanic/Latino, Asian, Hawaiian/Pacific Islanders, American Indian/Alaskan) who receive education, mentoring, and guidance to increase their interest and entry into MCH public health and related fields MCH Populations: Includes women, infants and children, adolescents, young adults, and their families including fathers, and children and youth with special health care needs
BENCHMARK DATA SOURCES	Related to Healthy People 2020: Access Goal: Improve access to comprehensive, high-quality health care services Educational Community Based Program Goal: Increase the quality, availability and effectiveness of educational and community-based programs designed to prevent disease and injury, improve health and enhance quality of life. Specific objectives: 10-11 Related to Public Health Infrastructure: To ensure that Federal, Tribal, State, and local health agencies have the necessary infrastructure to effectively provide essential public health services. Specific objectives: 2, 3, and 5
GRANTEE DATA SOURCES	A pipeline program follow-up survey will be used to collect these data. Data Sources Related to Training and Work Settings/Populations: Rittenhouse Diane R, George E. Fryer, Robert L. Pillips et al. Impact of Title Vii Training Programs on Community Health Center Staffing and National Health Service Corps Participation. Ann Fam Med 2008;6:397-405. DOI: 10.1370/afm.885. Karen E. Hauer, Steven J. Durning, Walter N. Kernan, et al. Factors Associated With Medical Students' Career Choices Regarding Internal Medicine JAMA. 2008;300(10):1154-1164 (doi:10.1001/jama.300.10.1154)
SIGNIFICANCE	HRSA’s MCHB places special emphasis on improving service delivery to women, children and youth from communities with limited access to comprehensive care.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 07 - MCH Pipeline Program

MCH Pipeline Program graduates who report working with the maternal and child health population (i.e., women, infants, children, adolescents, young adults, and their families, including and children with special health care needs) 2 years and 5 years after graduating from their MCH Pipeline program.

NOTE: If the individual works with more than one of these groups only count them once.

2 YEARS AFTER GRADUATING FROM MCH PIPELINE PROGRAM

A. The total number of graduates, 2 years following completion of program _________

B. The total number of graduates lost to follow-up

_________

C. The total number of respondents (A-B) = denominator

_________

D. Number of respondents who report working with an MCH population

since graduating from the MCH Pipeline Training Program _________

E. Percent of respondents who report working with an MCH population

Since graduating from the MCH Pipeline Training Program _________

5 YEARS AFTER GRADUATING FROM MCH PIPELINE PROGRAM

A. The total number of graduates, 5 years following completion of program _________

B. The total number of graduates lost to follow-up _________

C. The total number of respondents (A-B) = denominator _________

D. Number of respondents who report working with an MCH population

since graduating from the MCH Pipeline Training Program _________

E. Percent of respondents who report working with an MCH population

since graduating from the MCH Pipeline Training Program _________

Training 08 PERFORMANCE MEASURE Goal: MCH Pipeline Program Level: Grantee Domain: MCH Workforce Development	The percent of MCH Pipeline Program graduates who have been engaged in work with populations considered to be underserved or vulnerable.
GOAL	To increase the percent of graduates of MCH Pipeline Programs who have been engaged in work with populations considered to be underserved or vulnerable.
MEASURE	The percent of MCH Pipeline Program graduates who have been engaged in work with populations considered to be underserved or vulnerable since graduating from the MCH Pipeline Training Program.
DEFINITION	Numerator: Number of pipeline graduates reporting they have been engaged in work with populations considered underserved or vulnerable since graduating from the MCH Pipeline Training Program. Denominator: The total number of trainees responding to the survey Units: 100 Text: Percent
DEFINITION (cont…)	MCH Pipeline trainees are defined as undergraduate students from economically and educationally disadvantaged backgrounds (including underrepresented racial and ethnic minorities: African American, Hispanic/Latino, Asian, Hawaiian/Pacific Islanders, American Indian/Alaskan) who receive education, mentoring, and guidance to increase their interest and entry into MCH public health and related fields The term “underserved” refers to “Medically Underserved Areas and Medically Underserved Populations with shortages of primary medical care, dental or mental health providers. Populations may be defined by geographic (a county or service area) or demographic (low income, Medicaid-eligible populations, cultural and/or linguistic access barriers to primary medical care services) factors. The term "vulnerable groups," refers to social groups with increased relative risk (i.e. exposure to risk factors) or susceptibility to health-related problems. This vulnerability is evidenced in higher comparative mortality rates, lower life expectancy, reduced access to care, and diminished quality of life. This vulnerability is evidenced in higher comparative mortality rates, lower life expectancy, reduced access to care, and diminished quality of life. (i.e, Immigrant Populations Tribal Populations, Migrant Populations, Uninsured Populations, Individuals Who Have Experienced Family Violence, Homeless, Foster Care, HIV/AIDS, etc) Source: Center for Vulnerable Populations Research. UCLA. http://www.nursing.ucla.edu/orgs/cvpr/who-are-vulnerable.html
BENCHMARK DATA SOURCES	Related to Healthy People 2020: Access Goal: Improve access to comprehensive, high-quality health care services Educational Community Based Program Goal: Increase the quality, availability and effectiveness of educational and community-based programs designed to prevent disease and injury, improve health and enhance quality of life. Specific objectives: 10-11 Related to Public Health Infrastructure: To ensure that Federal, Tribal, State, and local health agencies have the necessary infrastructure to effectively provide essential public health services. Specific objectives: 2, 3, and 5
GRANTEE DATA SOURCES	A pipeline program follow-up survey will be used to collect these data. Data Sources Related to Training and Work Settings/Populations: Rittenhouse Diane R, George E. Fryer, Robert L. Pillips et al. Impact of Title Vii Training Programs on Community Health Center Staffing and National Health Service Corps Participation. Ann Fam Med 2008;6:397-405. DOI: 10.1370/afm.885. Karen E. Hauer, Steven J. Durning, Walter N. Kernan, et al. Factors Associated With Medical Students' Career Choices Regarding Internal Medicine JAMA. 2008;300(10):1154-1164 (doi:10.1001/jama.300.10.1154)
SIGNIFICANCE	HRSA’s MCHB places special emphasis on improving service delivery to women, children and youth from communities with limited access to comprehensive care.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 08 - MCH Pipeline Program

MCH Pipeline Program graduates who have worked with populations considered underserved or vulnerable 2 years and 5 years after graduating from their MCH Pipeline program.

NOTE: If the individual works with more than one of these groups only count them once.

2 YEARS AFTER GRADUATING FROM MCH PIPELINE PROGRAM

A. The total number of graduates, 2 years following completion of program

_________

B. The total number of graduates lost to follow-up

_________

C. The total number of respondents (A-B) = denominator

_________

D. Number of respondents who have worked with populations considered to

be underserved or vulnerable since graduating from the MCH Pipeline Training Program

_________

E. Percent of respondents who have worked with populations considered to

be underserved or vulnerable since graduating from the MCH Pipeline Training Program

_________

5 YEARS AFTER GRADUATING FROM MCH PIPELINE PROGRAM

A. The total number of graduates, 5 years following completion of program

_________

B. The total number of graduates lost to follow-up

_________

C. The total number of respondents (A-B) = denominator

_________

D. Number of respondents who have worked with populations considered to

be underserved or vulnerable since graduating from the MCH Pipeline Training Program

_________

E. Percent of respondents who have worked with populations considered to

be underserved or vulnerable since graduating from the MCH Pipeline Training Program

_________

Training 09 PERFORMANCE MEASURE Goal: Graduate Program Enrollment Level: Grantee Domain: MCH Workforce Development	The percent of pipeline graduates that enter graduate programs preparing them to work with the MCH population.
GOAL	To increase the number of pipeline graduates that enter graduate programs preparing them to work with the MCH population.
MEASURE	The percent of pipeline graduates that enter graduate programs preparing them to work with the MCH population.
DEFINITION	Numerator: Total number of MCH Pipeline trainees enrolled in or who have completed a graduate school program* preparing them to work with the MCH population, 2 or 5 years after graduating from the MCH Pipeline program. *Graduate programs preparing students to work with the MCH population include: pediatric medicine, public health, pediatric nutrition, public health social work, pediatric nursing, pediatric dentistry, psychology, health education, health administration, pediatric occupational/physical therapy, or speech language pathology. Denominator: Total number of MCH Pipeline Trainees who graduated from the MCH pipeline program 2 or 5 years previously.
BENCHMARK DATA SOURCES	Related to Healthy People 2020 Objectives: ECBP-12: Increase the inclusion of core clinical preventive and population health content in M.D.-granting medical schools ECBP-13: Increase the inclusion of core clinical preventive and population health content in D.O.-granting medical schools ECBP-14: Increase the inclusion of core clinical preventive and population health content in undergraduate nursing ECBP-15: Increase the inclusion of core clinical preventive and population health content in nurse practitioner training ECBP-16: Increase the inclusion of core clinical preventive and population health content in physician assistant training PHI-1: Increase the proportion of Federal, Tribal, State, and local public health agencies that incorporate Core Competencies for Public Health Professionals into job descriptions and performance evaluations
GRANTEE DATA SOURCES	Attached data collection form to be completed by grantees.
SIGNIFICANCE	MCHB training programs assist in developing a public health workforce that addresses key MCH issues and fosters field leadership in the MCH arena.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 09 – Graduate Program Enrollment

2 YEARS AFTER GRADUATING FROM MCH PIPELINE PROGRAM

A. The total number of Pipeline Trainees, 2 years following graduation from the program _________

B. The total number of graduates lost to follow-up ________

C. The total number of respondents (A-B) = denominator ________

D. Number of respondents that are enrolled in or have completed graduate

Programs preparing them work with the MCH population** ________

E. Percent of respondents that are enrolled in or have completed graduate

Programs preparing them work with the MCH population ________

5 YEARS AFTER GRADUATING FROM MCH PIPELINE PROGRAM

A. The total number of Pipeline Trainees, 5 years following graduation from the program _________

B. The total number of graduates lost to follow-up ________

C. The total number of respondents (A-B) = denominator ________

D. Number of respondents that are enrolled in or have completed graduate

Programs preparing them work with the MCH population** ________

E. Percent of respondents that are enrolled in or have completed graduate

Programs preparing them work with the MCH population ________

**Graduate programs preparing graduate students to work in the MCH population include:

Pediatric medicine, public health, pediatric nutrition, public health social work, pediatric nursing, pediatric dentistry, psychology, health education, health administration, pediatric occupational/physical therapy, speech language pathology.

Training 10 PERFORMANCE MEASURE Goal: Field Leadership Level: Grantee Domain: MCH Workforce Development	The percent of long term trainees that have demonstrated field leadership after completing an MCH training program.
GOAL	To increase the percentage of long term trainees that have demonstrated field leadership two and five years after completing their MCH Training Program.
MEASURE	The percentage of long-term trainees that have demonstrated field leadership after completing an MCH Training Program.
DEFINITION	Attached is a checklist of four elements that demonstrate field leadership. For each element, identify the number of long-term trainees that have demonstrated field leadership two and five years after program completion. Please keep the completed checklist attached. Long-term trainees are defined as those who have completed a long-term (greater than or equal to 300 contact hours) MCH training program, including those who received MCH funds and those who did not. “Field leadership” refers to but is not limited to providing MCH leadership within the clinical, advocacy, academic, research, public health, public policy or governmental realms. Refer to attachment for complete definition. Cohort is defined as those who have completed an MCHB-funded training program 2 years and 5 years prior to the reporting period. Data form for each cohort year will be collected for five years.
BENCHMARK DATA SOURCES	Related to Healthy People 2020 Objectives: PHI-1: Increase the proportion of Federal, Tribal, State and local public health agencies that incorporate Core Competencies for Public Health Professionals into job descriptions and performance evaluations PHI-3: Increase the proportion of Council on Education for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs and schools of nursing (with public health or community health component) that integrate Core Competencies for Public Health Professionals into curricula
GRANTEE DATA SOURCES	Attached data collection form to be completed by grantees.
SIGNIFICANCE	An MCHB trained workforce is a vital participant in clinical, administrative, policy, public health and various other arenas. MCHB long term training programs assist in developing a public health workforce that addresses MCH concerns and fosters field leadership in the MCH arena.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 10 – Field Leadership

SECTION A: 2 YEAR FOLLOW-UP

Numerator: The number of long-term trainees who have demonstrated field leadership 2 years after completing their MCH Training Program.

Denominator: The total number of long-term trainees, 2 years following completion of an MCHB-funded training program, included in this report.

Long-term trainees are defined as those who have completed a long-term (greater than or equal to 300 contact hours) MCH training program, including those who received MCH funds and those who did not.

The total number of long-term trainees, 2 years post program completion, included in this report	________
The total number of program completers lost to follow-up	________
Number of respondents (A-B) Number of respondents who have demonstrated field leadership in at least one of the following areas below Percent of long-term trainees (2 years post program completion) who have demonstrated field leadership in at least one of the following areas: (Individual respondents may have leadership activities in multiple areas below)	________ ________ ________
Number of trainees that have participated in academic leadership activities since completing their MCH Training Program Disseminated information on MCH Issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care) Conducted research or quality improvement on MCH issues  Provided consultation or technical assistance in MCH areas  Taught/mentored in my discipline or other MCH related field  Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process) Procured grant and other funding in MCH areas Conducted strategic planning or program evaluation	________
Number of trainees that have participated in clinical leadership activities since completing their MCH Training Program Participated as a group leader, initiator, key contributor or in a position of influence/authority on any of the following: committees of State, national, or local organizations; task forces; community boards; advocacy groups; research societies; professional societies; etc. Served in a clinical position of influence (e.g. director, senior therapist, team leader, etc Taught/mentored in my discipline or other MCH related field Conducted research or quality improvement on MCH issues  Disseminated information on MCH Issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care) Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)	________
3. Number of trainees that have participated in public health practice leadership activities since completing their MCH Training Program Provided consultation, technical assistance, or training in MCH areas Procured grant and other funding in MCH areas Conducted strategic planning or program evaluation Conducted research or quality improvement on MCH issues  Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process) Participated in public policy development activities (e.g., Participated in community engagement or coalition building efforts, written policy or guidelines, provided testimony, educated policymakers, etc.)	_______
4. Number of trainees that have participated in public policy & advocacy leadership activities since completing their MCH Training Program Participated in public policy development activities (e.g., participated in community engagement or coalition building efforts, written policy or guidelines, influenced MCH related legislation, provided testimony, educated legislators) Participated on any of the following as a group leader, initiator, key contributor, or in a position of influence/authority: committees of State, national, or local organizations; task forces; community boards; advocacy groups; research societies; professional societies; etc. Disseminated information on MCH public policy issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care, commentaries, and chapters)	_______

SECTION B: 5 YEAR FOLLOW-UP

Numerator: The number of long-term trainees who have demonstrated field leadership 5 years after completing their MCH Training Program.

Denominator: The total number of long-term trainees, 5 years following completion of an MCHB-funded training program, included in this report.

Long-term trainees are defined as those who have completed a long-term (greater than or equal to 300 contact hours) MCH training program, including those who received MCH funds and those who did not.

The total number of long-term trainees, 5 years post program completion, included in this report	_________
The total number of program completers lost to follow-up	_________
Number of respondents (A-B) Number of respondents who have demonstrated field leadership in at least one of the following areas below Percent of long-term trainees (5 years post program completion) who have demonstrated field leadership in at least one of the following areas: (Individual respondents may have leadership activities in multiple areas below)	________ ________ ________
1. Number of trainees that have participated in academic leadership activities since completing their MCH Training Program Disseminated information on MCH Issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care) Conducted research or quality improvement on MCH issues  Provided consultation or technical assistance in MCH areas  Taught/mentored in my discipline or other MCH related field  Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process) Procured grant and other funding in MCH areas Conducted strategic planning or program evaluation	________
2. Number of trainees that have participated in clinical leadership activities since completing their MCH Training Program Participated as a group leader, initiator, key contributor or in a position of influence/authority on any of the following: committees of State, national, or local organizations; task forces; community boards; advocacy groups; research societies; professional societies; etc. Served in a clinical position of influence (e.g. director, senior therapist, team leader, etc Taught/mentored in my discipline or other MCH related field Conducted research or quality improvement on MCH issues  Disseminated information on MCH Issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care) Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)	_______
3. Number of trainees that have participated in public health practice leadership activities since completing their MCH Training Program Provided consultation, technical assistance, or training in MCH areas Procured grant and other funding in MCH areas Conducted strategic planning or program evaluation Conducted research or quality improvement on MCH issues  Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process) Participated in public policy development activities (e.g., Participated in community engagement or coalition building efforts, written policy or guidelines, provided testimony, educated policymakers , etc.)	_______
4. Number of trainees that have participated in public policy & advocacy leadership activities since completing their MCH Training Program Participated in public policy development activities (e.g., participated in community engagement or coalition building efforts, written policy or guidelines, influenced MCH related legislation, provided testimony, educated legislators) Participated on any of the following as a group leader, initiator, key contributor, or in a position of influence/authority: committees of State, national, or local organizations; task forces; community boards; advocacy groups; research societies; professional societies; etc. Disseminated information on MCH public policy issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care, commentaries, and chapters)	______

NOTES/COMMENTS:

Training 11 PERFORMANCE MEASURE Goal: Long-term trainees working with MCH populations Level: Grantee Domain: MCH Workforce Development	The percentage of long-term trainees who are engaged in work focused on MCH populations after completing their MCH Training Program.
GOAL	To increase the percent of long-term trainees engaged in work focused on MCH populations two and five years after completing their MCH Training Program.
MEASURE	The percentage of long-term trainees who are engaged in work focused on MCH populations after completing their MCH Training Program.
DEFINITION	Numerator: Number of long-term trainees reporting they are engaged in work focused on MCH populations after completing their MCH Training Program. Denominator: The total number of trainees responding to the survey  Units: 100 Text: Percent  Long-term trainees are defined as those who have completed a long-term (greater than or equal to 300 contact hours) MCH Training Program, including those who received MCH funds and those who did not. Cohort is defined as those who have completed an MCHB-funded training program 2 years and 5 years prior to the reporting period. MCH Populations: Includes all of the Nation’s women, infants, children, adolescents, young adults and their families, including and children with special health care needs.
BENCHMARK DATA SOURCES	Related to ECBP-10 Increase the number of community-based organizations (including local health departments, Tribal health services, nongovernmental organizations, and State agencies) providing population-based primary prevention services… Related to ECBP-11(Developmental) Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs. Related to PHI-1Increase the proportion of Federal, Tribal, State, and local public health agencies that incorporate Core Competencies for Public Health Professionals into job descriptions and performance
GRANTEE DATA SOURCES	A revised trainee follow-up survey that incorporates the new form for collecting data on the involvement of those completing an MCH training program in work related to MCH populations will be used to collect these data.  Data Sources Related to Training and Work Settings/Populations: Rittenhouse Diane R, George E. Fryer, Robert L. Pillips et al. Impact of Title Vii Training Programs on Community Health Center Staffing and National Health Service Corps Participation. Ann Fam Med2008;6:397-405. DOI: 10.1370/afm.885.  Karen E. Hauer, Steven J. Durning, Walter N. Kernan, et al. Factors Associated With Medical Students' Career Choices Regarding Internal Medicine JAMA.2008;300(10):1154-1164 (doi:10.1001/jama.300.10.1154).
SIGNIFICANCE	HRSA’s MCHB places special emphasis on improving service delivery to women, children and youth from communities with limited access to comprehensive care.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 11 - Long-term trainees working with MCH populations

Individuals completing a long-term training program who report working with the maternal and child health population (i.e., women, infants, children, adolescents, young adults and their families, including children with special health care needs) at 2 years and at 5 years after completing their training program. 

NOTE: If the individual works with more than one of these groups only count them once. 

2 YEAR FOLLOW-UP
A. The total number of long-term trainees, 2 years following program completion	______
B. The total number of long-term trainees lost to follow-up (2 years following program completion)	______
C. The total number of respondents (A-B) = denominator	______
D. Number of respondents 2 years following completion of program who report working with an MCH population	______
E. Percent of respondents 2 years following completion of program who report working with an MCH population

__________________________________________________

5 YEAR FOLLOW-UP
F. The total number of long-term trainees, 5 years following program completion	______
G. The total number of long-term trainees lost to follow-up (5 years following program completion),	______
H. The total number of respondents (F-G) = denominator	______
I. Number of respondents 5 years following completion of program who report working with an MCH population	______
J. Percent of respondents 5 years following completion of program who report working with an MCH population

Training 12 PERFORMANCE MEASURE Goal: Long-term Trainees Level: Grantee Domain: MCH Workforce Development	The percent of long-term trainees who, at 2, 5 and 10 years post training, have worked in an interdisciplinary manner to serve the MCH population (e.g., individuals with disabilities and their families, adolescents and their families, etc.).
GOAL	To increase the percent of long-term trainees who, upon completing their training, work in an interdisciplinary manner to serve the MCH population.
MEASURE	The percent of long-term trainees who, at 2, 5 and 10 years post training have worked in an interdisciplinary manner to serve the MCH population.
DEFINITION	Numerator:		The number of long-term trainees indicating that they have worked in an interdisciplinary manner serving the MCH population.
	Denominator:		The total number of long-term trainees responding to the survey
	Units:	100		Text:	Percent
	In addition, data on the total number of the long-term trainees and the number of non-respondents for each year will be collected. Long-term trainees are defined as those who have completed a long-term (300+ hours) MCH Training program, including those who received MCH funds and those who did not.
BENCHMARK DATA SOURCES	Related to Healthy People 2020 Objectives: ECBP-12: Increase the inclusion of core clinical preventive and population health content in M.D.-granting medical schools ECBP-13: Increase the inclusion of core clinical preventive and population health content in D.O.-granting medical schools ECBP-14: Increase the inclusion of core clinical preventive and population health content in undergraduate nursing ECBP-15: Increase the inclusion of core clinical preventive and population health content in nurse practitioner training ECBP-16: Increase the inclusion of core clinical preventive and population health content in physician assistant training PHI-3: Increase the proportion of Council on Education for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs and schools of nursing (with a public health or community health component) that integrate Core Competencies for Public Health Professionals into curricula MICH-31: Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems
GRANTEE DATA SOURCES	The trainee follow-up survey is used to collect these data.
SIGNIFICANCE	Leadership education is a complex interdisciplinary field that must meet the needs of MCH populations. This measure addresses one of a training program’s core values and its unique role to prepare professionals for comprehensive systems of care/practice. By providing interdisciplinary coordinated care, training programs help to ensure that all MCH populations receive the most comprehensive care that takes into account the complete and unique needs of the individuals and their families.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 12 – Long-term Trainees

1. 2 YEAR FOLLOW-UP

Numerator: The number of long-term trainees who have worked in an interdisciplinary manner 2 years following completion of an MCHB-funded training program, demonstrating at least one of the interdisciplinary skills listed.

Denominator: The total number of long-term trainees, 2 years following completion of an MCHB-funded training program, responding to the survey

The total number of long-term trainees, 2 years following program completion	_________
The total number of program completers lost to follow-up	_________
Number of respondents (Denominator)	_________
The number of long-term trainees who have worked in an interdisciplinary manner 2 years following completion of an MCHB-funded training program, demonstrating at least one of the interdisciplinary skills listed	_________
The total number of program completers lost to follow-up
Percent of long-term trainees (2 years post program completion) who have worked in an interdisciplinary manner, demonstrating at least one of the following interdisciplinary skills:	________%
Sought input or information from other professions or disciplines to address a need in your work	________%
Provided input or information to other professions or disciplines.	________%
Developed a shared vision, roles and responsibilities within an interdisciplinary group.	________%
Utilized that information to develop a coordinated, prioritized plan across disciplines to address a need in your work	________%
Established decision-making procedures in an interdisciplinary group.	________%
Collaborated with various disciplines across agencies/entities?	________%
Advanced policies & programs that promote collaboration with other disciplines or professions	________%

B. 5 YEAR FOLLOW-UP

Numerator: The number of long-term trainees who have worked in an interdisciplinary manner 5 years following completion of an MCHB-funded training program, demonstrating at least one of the interdisciplinary skills listed.

Denominator: The total number of long-term trainees, 5 years following completion of an MCHB-funded training program, responding to the survey.

The total number of long-term trainees, 5 years following program completion	_________
The total number of program completers lost to follow-up	_________
The number of long-term trainees who have worked in an interdisciplinary manner 5 years following completion of an MCHB-funded training program, demonstrating at least one of the interdisciplinary skills listed	_________
Percent of long-term trainees (5 years post program completion) who have worked in an interdisciplinary manner, demonstrating at least one of the following interdisciplinary skills:	________%
Sought input or information from other professions or disciplines to address a need in your work	________%
Provided input or information to other professions or disciplines.	________%
Developed a shared vision, roles and responsibilities within an interdisciplinary group.	________%
Utilized that information to develop a coordinated, prioritized plan across disciplines to address a need in your work	________%
Established decision-making procedures in an interdisciplinary group.	________%
Collaborated with various disciplines across agencies/entities?	________%
Advanced policies & programs that promote collaboration with other disciplines or professions	________%

C. 10 YEAR FOLLOW-UP

Numerator: The number of long-term trainees who have worked in an interdisciplinary manner 10 years following completion of an MCHB-funded training program, demonstrating at least one of the interdisciplinary skills listed.

Denominator: The total number of long-term trainees, 10 years following completion of an MCHB-funded training program, responding to the survey.

The total number of long-term trainees, 10 years following program completion	_________
The total number of program completers lost to follow-up	_________
Percent of long-term trainees (10 years post program completion) who have worked in an interdisciplinary manner, demonstrating at least one of the following interdisciplinary skills:	________%
Sought input or information from other professions or disciplines to address a need in your work	________%
Provided input or information to other professions or disciplines.	________%
Developed a shared vision, roles and responsibilities within an interdisciplinary group.	________%
Utilized that information to develop a coordinated, prioritized plan across disciplines to address a need in your work	________%
Established decision-making procedures in an interdisciplinary group.	________%
Collaborated with various disciplines across agencies/entities?	________%
Advanced policies & programs that promote collaboration with other disciplines or professions	________%

Training 13 PERFORMANCE MEASURE Goal: Diverse Adolescent Involvement Level: Grantee Domain: MCH Workforce Development	The degree to which the LEAH program incorporates adolescents and parents from diverse ethnic and cultural backgrounds as advisors and participants in program activities.
GOAL	To increase appropriate involvement of adolescents and parents as consumers of LEAH program activities.
MEASURE	The degree to which adolescents and parents are incorporated as consumers of LEAH program activities.
DEFINITION	Attached is a checklist of 4 elements that document adolescent and parent participation. Respondents will note the presence or absence of this participation on a scale of 0-1 for a total possible score of 4.
BENCHMARK DATA SOURCES	Related to Objective HC/HIT-2: Increase the proportion of persons who report that their health care providers have satisfactory communication skills.
GRANTEE DATA SOURCES	Grantees report using a data collection form. These data may be collected with the LEAH self-assessment activities. Participation should be defined to permit assessment of youth and young adult involvement.
SIGNIFICANCE	Over the last decade, policy makers and program administrators have emphasized the central role of consumer of health services as advisors and participants in program activities. Satisfaction with health care is related to satisfaction with the quality of the communication with health providers. In accordance with this philosophy, LEAH facilitates such partnerships and believes that consumers (adolescents and parents) from diverse backgrounds have important roles in the training of future leaders in adolescent health care delivery systems.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 13 – Adolescent Involvement

Indicate the degree to which your training program has the active involvement of adolescents and parents in your program and planning activities using the following values:

0 = No 1 = Yes

Element	0	1
Adolescents from diverse ethnic backgrounds and cultures participate in an advisory capacity.
Parents of adolescents from diverse ethnic backgrounds and cultures participate in an advisory capacity.
Adolescents from diverse ethnic backgrounds and cultures participate in the planning, implementation and evaluation of program activities related to adolescents as consumers
Parents of adolescents from diverse ethnic backgrounds and cultures participate in the planning, implementation and evaluation of program activities related to parents as consumers

Total Score (possible 0‑4 score) ________

Training 14 PERFORMANCE MEASURE Goal: Medium-Term Trainees Skill and Knowledge Level: Grantee Domain: MCH Workforce Development	The percentage of Level I medium term trainees who report an increase in knowledge and the percentage of Level II medium term trainees who report an increase in knowledge or skills related to MCH core competencies .
GOAL	To increase the percentage of medium term trainees (MTT) who report increased knowledge or skills related to MCH core competencies.
MEASURE	The percentage of Level I medium term trainees who report an increase in knowledge and the percentage of Level II medium term trainees who report an increase in knowledge or skills related to MCH core competencies.
DEFINITION	Numerator: The number of Level I medium term trainees who report an increase in knowledge and Level II medium term trainees who report an increase in knowledge or skills related to MCH core competencies. Denominator: The total number of medium term trainees responding to the survey. Medium Term trainees: Level I MTT complete 40-149 hours of training. Level II MTT complete 150–299 hours of training.
BENCHMARK DATA SOURCES	MICH-31: Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, and coordinated systems. ECBP-19: Increase the proportion of academic institutions with health professions education programs whose prevention curricula include interprofessional educational experiences. ECBP-12.2: Increase the inclusion of cultural diversity content in M.D.-granting medical schools. ECBP-13.2: Increase the inclusion of cultural diversity content in D.O.-granting medical schools. ECBP-15.2: Increase the inclusion of cultural diversity content in nurse practitioner training. ECBP-17.2: Increase the inclusion of cultural diversity content in Doctor of Pharmacy (PharmD) granting colleges and schools of pharmacy.
GRANTEE DATA SOURCES	End of training survey is used to collect these data.
SIGNIFICANCE	Medium Term trainees comprise a significant proportion of training efforts. These trainees impact the provision of care to CYSHCN nationally. The impact of this training must be measured and evaluated.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 14 – Medium-Term Trainees Skill and Knowledge

Level I Medium Term Trainees - Knowledge

1. The total number of Level I Medium-Term Trainees (40-149 hours) _______

2. The total number of Level I MTT lost to follow-up _______

3. The total number of respondents (A-B) _______

4. Number of respondents reporting increased knowledge _______

5. Percentage of respondents reporting increased knowledge _______

Level II Medium Term Trainees – Knowledge:

1. The total number of Level II Medium-Term Trainees (150-299 hours) _______

2. The total number of Level II MTT lost to follow-up _______

3. The total number of respondents (A-B) _______

4. Number of respondents reporting increased knowledge _______

5. Percentage of respondents reporting increased knowledge _______

Level II Medium Term Trainees - Skills :

1. The total number of Level II Medium-Term Trainees (150-299 hours) ________

2. The total number of Level II MTT lost to follow-up ________

3. The total number of respondents (A-B) ________

4. Number of respondents reporting increased skills ________

5. Percentage of respondents reporting increased skills ________

DIVISION OF CHILD ADOLESCENT, AND FAMILY HEALTH

Emergency Medical Services for Children Program PERFORMANCE MEASURE DETAIL SHEET SUMMARY TABLE

Performance Measure	New/Revised Measure	Prior PM Number (if applicable)	Topic
EMSC 01	New	N/A	Using NEMSIS Data to Identify Pediatric Patient Care Needs.
EMSC 02	New	N/A	Pediatric Emergency Care Coordination
EMSC 03	New	N/A	Use of pediatric-specific equipment
EMSC 04	Unchanged	74	Pediatric medical emergencies
EMSC 05	Unchanged	75	Pediatric traumatic emergencies
EMSC 06	Unchanged	76	Written inter-facility transfer guidelines that contain all the components as per the implementation manual.
EMSC 07	Unchanged	77	Written inter-facility transfer agreements that covers pediatric patients.
EMSC 08	Unchanged	79	Established permanence of EMSC
EMSC 09	Updated	80	Established permanence of EMSC by integrating EMSC priorities into statutes/regulations.

EMSC 01 PERFORMANCE MEASURE Goal: Submission of NEMSIS compliant version 3.x data Level: Grantee Domain: Emergency Medical Services for Children	The degree to which EMS agencies submit NEMSIS compliant version 3.x data to the State EMS Office.
GOAL	By 2018, baseline data will be available to assess the number of EMS agencies in the state/territory that submit National Emergency Medical Services Information System (NEMSIS) version 3.X compliant patient care data to the State Emergency Medical Services (EMS) Office for all 911 initiated EMS activations. By 2021, 80% of EMS agencies in the state/territory submit NEMSIS version compliant patient care data to the State EMS Office for all 911 initiated EMS activations.
MEASURE	The degree to which EMS agencies submit NEMSIS compliant version 3.x data to the State EMS Office.
DEFINITION	Numerator: The number of EMS agencies in the state/territory that submit NEMSIS version 3.X compliant patient care data to the State Emergency Medical Services Office. Denominator: Total number of EMS agencies in the state/territory actively responding to 911 requests for assistance. Units: 100 Text: Percent
	EMS: Emergency Medical Services EMS Agency: A prehospital provider agency. An EMS agency is defined as an organization staffed with personnel who are actively rendering medical care in response to a 911 or similar emergency call. Data will be gathered from State EMS Offices for both transporting and non-transporting agencies (excludes air- and water-only EMS services). NEMSIS: National EMS Information System. NEMSIS is the national repository that is used to store EMS data from every state in the nation. NEMSIS Version 3.X compliant patient care data: A national set of standardized data elements collected by EMS agencies. NEMSIS Technical Assistance Center (TAC): The NEMSIS TAC is the resource center for the NEMSIS project. The NEMSIS TAC provides assistance states, territories, and local EMS agencies, creates reference documents, maintains the NEMSIS database and XML schemas, and creates compliance policies. NHTSA – National Highway Traffic Safety Administration
HRSA STRATEGIC OBJECTIVE	Improve Access to Quality Health Care and Services by strengthening health systems to support the delivery of quality health services. Improve Health Equity by monitoring, identifying, and advancing evidence-based and promising practices to achieve health equity.
GRANTEE DATA SOURCES	State EMS Offices
SIGNIFICANCE	Access to quality data and effective data management play an important role in improving the performance of an organization’s health care systems. Collecting, analyzing, interpreting, and acting on data for specific performance measures allows health care professionals to identify where systems are falling short, to make corrective adjustments, and to track outcomes. However, uniform data collection is needed to consistently evaluate systems and develop Quality Improvement programs. The NEMSIS operated by the National Highway Traffic Safety Administration, provides a basic platform for states and territories to collect and report patient care data in a uniform manner. NEMSIS enables both state and national EMS systems to evaluate their current prehospital delivery. As a first step toward Quality Improvement (QI) in pediatric emergency medical and trauma care, the EMSC Program seeks to first understand the proportion of EMS agencies reporting to the state EMS office NEMSIS version 3.X compliant data, then use that information to identify pediatric patient care needs and promote its full use at the EMS agency level. In the next few years, NEMSIS will enable states and territories to evaluate patient outcomes and as a result, the next phase will employ full utilization of NEMSIS data on specific measures of pediatric data utilization. This will include implementing pediatric-specific EMS Compass measures in states, publishing results, publishing research using statewide EMS kids data, linking EMS data, providing performance information back to agencies, and building education programs around pediatric data, etc. This measure also aligns with the Healthy People 2020 objective PREP-19: Increase the number of states reporting 90% of emergency medical services (EMS) calls to National EMS Information System (NEMSIS) using the current accepted dataset standard. While most localities collect and most states report NEMSIS version 2.X compliant data currently, NEMSIS version 3.x is available today and in use in several states. Version 3 includes an expanded data set, which significantly increases the information available on critically ill or injured children. NHTSA is encouraging states and localities to upgrade to version 3.X compliant software and submit version 3.X data by January 1, 2017.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 01

The percentage of EMS agencies in the state/territory that submit National Emergency Medical Services Information System (NEMSIS) version 3.X compliant patient care data to the State Emergency Medical Services Office for all 911 initiated EMS activations.

State EMS Offices will be asked to select which of six (6) statements best describes their current status. The measure will be determined on a scale of 0-5. The following table shows the scoring rubric for responses. Achievement for grantees will be reached when 80% of EMS agencies are submitting NEMSIS version 3.X compliant patient care data to the State EMS Office. This is represented by a score of “5”.

Which statement best describes your current status?	Current Progress
Our State EMS Office has not yet transitioned to NEMSIS compliant version 3.x.	0
Our State EMS Office intends to transition to NEMSIS version 3.X compliant patient care data to submit to NEMSIS TAC by or before 2021.	1
Our State EMS Office submits NEMSIS version 3.X compliant patient care data to NEMSIS TAC with less than 10% of EMS agencies reporting.	2
Our State EMS Office submits NEMSIS version 3.X compliant patient care data to NEMSIS TAC with at least 10% and less than 50% of the EMS agencies reporting.	3
Our State EMS Office submits NEMSIS version 3.X compliant patient care data to NEMSIS TAC with at least 50% and less than 80% of the EMS agencies reporting.	4
Our State EMS Office submits NEMSIS version 3.X compliant patient care data to NEMSIS TAC with at least 80% of the EMS agencies reporting.	5
Numerator: The number of EMS agencies in the state/territory that submit National Emergency Medical Services Information System (NEMSIS) version 3.X compliant patient care data to the State Emergency Medical Services Office for all 911 initiated EMS activations
Denominator: Total number of EMS agencies in the state/territory actively responding to 911 requests for assistance.
Percent:

Proposed Survey Questions:

As part of the HRSA’s quest to improve the quality of healthcare, the EMSC Program is interested to hear about current efforts to collect NEMSIS version 3.X compliant patient care data from EMS agencies in the state/territory. The EMSC Program aims to first understand the proportion of EMS agencies that are submitting NEMSIS version 3.X compliant patient care data to the state EMS office.

The NEMSIS Technical Assistance Center will only collect version 3.X compliant data beginning on January 1, 2017.

Which one of the following statements best describes your current status toward submitting NEMSIS version 3.X compliant patient care data to the NEMSIS TAC from currently active EMS agencies in the state/territory? (Choose one)

Our State EMS Office does not submit patient care data to the NEMSIS Technical Assistance Center (TAC)

Our State EMS Office intends to submit patient care data to the NEMSIS Technical Assistance Center (TAC) by or before 2021.

Our State EMS Office submits NEMSIS version 3.X compliant patient care data to the NEMSIS Technical Assistance Center (TAC) with less than 10% of EMS agencies reporting.

Our State EMS Office submits NEMSIS version 3.X compliant patient care data to the NEMSIS Technical Assistance Center (TAC) with at least 10% and less than 50% of EMS agencies reporting.

Our State EMS Office submits NEMSIS version 3.X compliant patient care data to the NEMSIS Technical Assistance Center (TAC) with at least 50% and less than 80% of EMS agencies reporting.

Our State EMS Office submits NEMSIS version 3.X compliant patient care data to the NEMSIS Technical Assistance Center (TAC) with at least 80% of EMS agencies reporting.

Annual targets for this measure:

Year	Target
2018	Baseline data
2019	10%
2020	50%
2021	80%

EMSC 02 PERFORMANCE MEASURE Goal: Pediatric Emergency Care Coordination Level: Grantee Domain: Emergency Medical Services for Children	The percentage of EMS agencies in the state/territory that have a designated individual who coordinates pediatric emergency care.
GOAL	By 2020, 30% of EMS agencies in the state/territory have a designated individual who coordinates pediatric emergency care. By 2023, 60% of EMS agencies in the state/territory have a designated individual who coordinates pediatric emergency care. By 2026, 90% of EMS agencies in the state/territory have a designated individual who coordinates pediatric emergency care.
MEASURE	The percentage of EMS agencies in the state/territory that have a designated individual who coordinates pediatric emergency care.
DEFINITION	Numerator: The number of EMS agencies in the state/territory that score a ‘3’ on a 0-3 scale. Denominator: Total number of EMS agencies in the state/territory that provided data. Units: 100 Text: Percent
	Recommended Roles: Job related activities that a designated individual responsible for the coordination of pediatric emergency care might oversee for your EMS agency are: Ensure that the pediatric perspective is included in the development of EMS protocols Ensure that fellow EMS providers follow pediatric clinical practice guidelines Promote pediatric continuing education opportunities Oversee pediatric process improvement Ensure the availability of pediatric medications, equipment, and supplies Promote agency participation in pediatric prevention programs Promote agency participation in pediatric research efforts Liaises with the emergency department pediatric emergency care coordinator Promote family-centered care at the agency EMS: Emergency Medical Services EMS Agency: An EMS agency is defined as an organization staffed with personnel who render medical care in response to a 911 or similar emergency call. Data will be gathered from both transporting and non-transporting agencies. IOM: Institute of Medicine
HRSA STRATEGIC OBJECTIVE	Strengthen the Health Workforce
GRANTEE DATA SOURCES	Survey of EMS agencies
SIGNIFICANCE	The Institute of Medicine (IOM) report “Emergency Care for Children: Growing Pains” (2007) recommends that EMS agencies and emergency departments (EDs) appoint a pediatric emergency care coordinator to provide pediatric leadership for the organization. This individual need not be dedicated solely to this role and could be personnel already in place with a special interest in children who assumes this role as part of their existing duties. Gausche-Hill et al in a national study of EDs found that the presence of a physician or nurse pediatric emergency care coordinator was associated with an ED being more prepared to care for children. EDs with a coordinator were more likely to report having important policies in place and a quality improvement plan that addressed the needs of children than EDs that reported not having a coordinator. The IOM report further states that pediatric coordinators are necessary to advocate for improved competencies and the availability of resources for pediatric patients. The presence of an individual who coordinates pediatric emergency care at EMS agencies may result in ensuring that the agency and its providers are more prepared to care for ill and injured children. The Pediatric Emergency Care Coordinator (PECC) should be a member of the EMS agency and be familiar with the day-to-day operations and needs at the agency. However, some states/territories may use a variety of models to coordinate pediatric emergency care at the county or regional levels. If there is a designated individual who coordinates pediatric activities for a county or region, that individual could serve as the PECC for one of more individual EMS agencies within the county or region.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 02

The percentage of EMS agencies in the state/territory that have a designated individual who coordinates pediatric emergency care.

Numerator: The number of EMS agencies in the state/territory that score a ‘3’ on a 0-3 scale.
Denominator: Total number of EMS agencies in the state/territory that provided data.
Percent:

EMS agencies will be asked to select which of four statements best describes their agency. The measure will be determined on a scale of 0-3. The following table shows the scoring rubric for responses.

Achievement for grantees will be reached when at least 90% of the EMS agencies in the state/territory report a ‘3’ on the scale below.

Which statement best defines your agency?	Scale
Our EMS agency does NOT have a designated INDIVIDUAL who coordinates pediatric emergency care at this time	0
Our EMS agency does NOT CURRENTLY have a designated INDIVIDUAL who coordinates pediatric emergency care but we would be INTERESTED IN ADDING this role	1
Our EMS agency does NOT CURRENTLY have a designated INDIVIDUAL who coordinates pediatric emergency care but we HAVE A PLAN TO ADD this role within the next year	2
Our EMS agency HAS a designated INDIVIDUAL who coordinates pediatric emergency care for our agency	3

Proposed Survey Questions:

Now we are interested in hearing about how pediatric emergency care is coordinated at your EMS agency. This is an emerging issue within emergency care and we want to gather information on what is happening across the country within EMS agencies.

One way that an agency can coordinate pediatric emergency care is by DESIGNATING AN INDIVIDUAL who is responsible for pediatric-specific activities that could include:

• Ensure that the pediatric perspective is included in the development of EMS protocols

• Ensure that fellow providers follow pediatric clinical practice guidelines

• Promote pediatric continuing education opportunities

• Oversee pediatric process improvement

• Ensure the availability of pediatric medications, equipment, and supplies

• Promote agency participation in pediatric prevention programs

• Promote agency participation in pediatric research efforts

• Liaise with the ED pediatric emergency care coordinator

• Promote family-centered care at the agency

A DESIGNATED INDIVIDUAL who coordinates pediatric emergency care need not be dedicated solely to this role; it can be an individual already in place who assumes this role as part of their existing duties. The individual may be located at your agency, county or region.

Which one of the following statements best describes your EMS agency? (Choose one)

Our EMS agency does NOT have a designated INDIVIDUAL who coordinates pediatric emergency care at this time

Our EMS agency does NOT CURRENTLY have a designated INDIVIDUAL who coordinates pediatric emergency care but we would be INTERESTED IN ADDING this role

Our EMS agency does NOT CURRENTLY have a designated INDIVIDUAL who coordinates pediatric emergency care but we HAVE A PLAN TO ADD this role within the next year

Our EMS agency HAS a designated INDIVIDUAL who coordinates pediatric emergency care

You indicated that you have a designated individual who coordinates pediatric emergency care at your EMS agency.

How many EMS agencies does this individual oversee?

Is this individual:

located at your agency

located at the county level

located at a regional level

Other, please describe

To guide in the coordination of pediatric emergency care, specific roles are recommended for this individual. At this time, these roles do not determine achievement of this performance measure. However, these roles do support a variety of segments in the coordination of pediatric emergency care. Does a designated individual…

(Check Yes or No for each of the following questions)

Ensure that the pediatric perspective is included in the development of EMS protocols

Yes No

Ensure that fellow providers follow pediatric clinical practice guidelines

Yes No

Promote pediatric continuing education opportunities

Yes No

Oversee pediatric process improvement

Yes No

Ensure the availability of pediatric medications, equipment, and supplies

Yes No

Promote agency participation in pediatric prevention programs

Yes No

Liaise with the emergency department pediatric emergency care coordinator

Yes No

Promote family-centered care at the agency

Yes No

Promote agency participation in pediatric research efforts

Yes No

Other

Yes
No

You marked ‘other’ to the previous question. Please describe the ‘other’ activity(s) performed by the designated individual who coordinates pediatric emergency care at your agency.

If you have any additional thoughts about pediatric emergency care coordination, please share them here:

EMSC 03 PERFORMANCE MEASURE Goal: Use of pediatric-specific equipment Level: Grantee Domain: Emergency Medical Services for Children	The percentage of EMS agencies in the state/territory that have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment.
GOAL	By 2020, 30% of EMS agencies will have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment, which is equal to a score of ‘6’ or more on a 0-12 scale. By 2023: 60% of EMS agencies will have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment, which is equal to a score of ‘6’ or more on a 0-12 scale. By 2026: 90% of EMS agencies will have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment, which is equal to a score of ‘6’ or more on a 0-12 scale.
MEASURE	The percentage of EMS agencies in the state/territory that have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment.
DEFINITION	Numerator: The number of EMS agencies in the state/territory that score a ‘6’ or more on a 0-12 scale. Denominator: Total number of EMS agencies in the state/territory that provided data. Units: 100 Text: Percent EMS: Emergency Medical Services EMS Agency: An EMS agency is defined as an organization staffed with personnel who render medical care in response to a 911 or similar emergency call. Data will be gathered from both transporting and non-transporting agencies. IOM: Institute of Medicine EMS Providers: EMS providers are defined as people/persons who are certified or licensed to provide emergency medical services during a 911 or similar emergency call. There are four EMS personnel licensure levels: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), and Paramedic. Reference the National Highway Traffic Safety Administration (NHTSA) National EMS Scope of Practice Model http://www.ems.gov/education/EMSScope.pdf
HRSA STRATEGIC OBJECTIVE	Goal I: Improve Access to Quality Health Care and Services (by improving quality) or; Goal II: Strengthen the Health Workforce
GRANTEE DATA SOURCES	Survey of EMS agencies
SIGNIFICANCE	The Institute of Medicine (IOM) report “Emergency Care for Children: Growing Pains” reports that because EMS providers rarely treat seriously ill or injured pediatric patients, providers may be unable to maintain the necessary skill level to care for these patients. For example, Lammers et al reported that paramedics manage an adult respiratory patient once every 20 days compared to once every 625 days for teens, 958 days for children and once every 1,087 days for infants. As a result, skills needed to care for pediatric patients may deteriorate. Another study by Su et al found that EMS provider knowledge rose sharply after a pediatric resuscitation course, but when providers were retested six months later; their knowledge was back to baseline. Continuing education such as the Pediatric Advance Life Support (PALS) and Pediatric Education for Prehospital Professionals (PEPP) courses are vitally important for maintaining skills and are considered an effective remedy for skill atrophy. These courses are typically only required every two years. More frequent practice of skills using different methods of skill ascertainment are necessary for EMS providers to ensure their readiness to care for pediatric patients when faced with these infrequent encounters. These courses may be counted if an in-person skills check is required as part of the course. Demonstrating skills using EMS equipment is best done in the field on actual patients but in the case of pediatric patients this can be difficult given how infrequently EMS providers see seriously ill or injured children. Other methods for assessing skills include simulation, case scenarios and skill stations. In the absence of pediatric patient encounters in the field. There is not definitive evidence that shows that one method is more effective than another for demonstrating clinical skills. But, Miller's Model of Clinical Competence posits via the skills complexity triangle that performance assessment can be demonstrated by a combination of task training, integrated skills training, and integrated team performance. In the EMS environment this can be translated to task training at skill stations, integrated skills training during case scenarios, and integrated team performance while treating patients in the field.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 03

The percentage of EMS agencies in the state/territory that have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment.

Numerator: The number of EMS agencies in the state/territory that score a ‘6’ or more on a 0-12 scale.
Denominator: Total number of EMS agencies in the state/territory that provided data.
Percent:

EMS agencies will be asked to select the frequency of each of three methods used to evaluate EMS providers’ use of pediatric-specific equipment. The measure will be determined on a scale of 0 – 12. The following table shows the scoring rubric for responses. Achievement for the grantees will be reached when at least 90% of the EMS agencies in a state/territory report a combined score of ‘6’ or higher from a combination of the methods.

	Two or more times per year	At least once per year	At least once every two years	Less frequency than once every two years
How often are your providers required to demonstrate skills via a SKILL STATION?	4	2	1	0
How often are your providers required to demonstrate skills via a SIMULATED EVENT?	4	2	1	0
How often are your providers required to demonstrate skills via a FIELD ENCOUNTER?	4	2	1	0

Proposed Survey Questions:

In the next set of questions we are asking about the process that EMS agencies use to evaluate their EMS providers’ skills using pediatric-specific equipment. While there are multiple processes that might be used, we are interested in the following three processes:

• At a skill station

• Within a simulated event

• During an actual pediatric patient encounter

At a SKILL STATION(not part of a simulated event), does your agency have a process which

REQUIRES your EMS providers to PHYSICALLY DEMONSTRATE the correct use of

PEDIATRIC- SPECIFIC equipment?

Yes No

How often is this process required for your EMS providers? (Choose one) Two or more times a year

At least once a year

At least once every two years

Less frequently than once every two years

Within A SIMULATED EVENT (such as a case scenario or a mock incident), does your agency have a process which REQUIRES your EMS providers to PHYSICALLY

DEMONSTRATE the correct use of PEDIATRIC- SPECIFIC equipment?

Yes No

How often is this process required for your EMS providers? (Choose one) Two or more times a year

At least once a year

At least once every two years

Less frequently than once every two years

During an actual PEDIATRIC PATIENT ENCOUNTER, does your agency have a process which REQUIRES your EMS providers to be observed by a FIELD TRAINING OFFICER or SUPERVISOR to ensure the correct use of PEDIATRIC- SPECIFIC equipment?

Yes No

How often is this process required for your EMS providers? (Choose one) Two or more times a year

At least once a year

At least once every two years

Less frequently than once every two years

If you have any additional thoughts about skill checking, please share them here:

EMSC 04 PERFORMANCE MEASURE Goal: Emergency Department Preparedness Level: Grantee Domain: Emergency Medical Services for Children	The percent of hospitals with an Emergency Department (ED) recognized through a statewide, territorial or regional standardized program that are able to stabilize and/or manage pediatric medical emergencies.
GOAL	By 2022: 25% of hospitals are recognized as part of a statewide, territorial, or regional standardized program that are able to stabilize and/or manage pediatric medical emergencies.
MEASURE	The percent of hospitals recognized through a statewide, territorial or regional program that are able to stabilize and/or manage pediatric medical emergencies.
DEFINITION	Numerator: Number of hospitals with an ED that are recognized through a statewide, territorial or regional standardized program that are able to stabilize and/or manage pediatric medical emergencies. Denominator: Total number of hospitals with an ED in the State/Territory. Units: 100 Text: Percent Standardized system: A system of care provides a framework for collaboration across agencies, health care organizations/services, families, and youths for the purposes of improving access and expanding coordinated culturally and linguistically competent care for children and youth. The system is coordinated, accountable and includes a facility recognition program for pediatric medical emergencies. Recognizing the pediatric emergency care capabilities of hospitals supports the development of a system of care that is responsive to the needs of children and extends access to specialty resources when needed. Hospital: Facilities that provide definitive medical and/or surgical assessment, diagnoses, and life and/or limb saving interventions for the ill and injured AND have an Emergency Department. Excludes Military and Indian Health Service hospitals.
EMSC STRATEGIC OBJECTIVE	Ensure the operational capacity and infrastructure to provide pediatric emergency care. Develop a statewide, territorial, or regional program that recognizes hospitals that are able to stabilize and/or manage pediatric medical emergencies..
GRANTEE DATA SOURCES	This performance measure will require grantees to determine how many hospitals participate in their facility recognition program (if the state has a facility recognition program) for medical emergencies.
SIGNIFICANCE	The performance measure emphasizes the importance of the existence of a standardized statewide, territorial, or regional system of care for children that includes a recognition program for hospitals capable of stabilizing and/or managing pediatric medical emergencies. A standardized recognition and/or designation program, based on compliance with the current published pediatric emergency/trauma care guidelines, contributes to the development of an organized system of care that assists hospitals in determining their capacity and readiness to effectively deliver pediatric emergency/trauma and specialty care. This measure helps to ensure essential resources and protocols are available in facilities where children receive care for medical and trauma emergencies. A recognition program can also facilitate EMS transfer of children to appropriate levels of resources. Additionally, a pediatric recognition program, that includes a verification process to identify facilities meeting specific criteria, has been shown to increase the degree to which EDs are compliant with published guidelines and improve hospital pediatric readiness statewide. In addition, Performance Measure EMSC 04 does not require that the recognition program be mandated. Voluntary facility recognition is accepted.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 04

The percent of hospitals with an Emergency Department (ED) that are recognized through a statewide, territorial or regional standardized program that are able to stabilize and/or manage pediatric medical emergencies.

Numerator:
Denominator:
Percent

Numerator: Number of hospitals with an ED that are recognized through a statewide, territorial or regional program that are able to stabilize and/or manage pediatric medical emergencies.

Denominator: Total number of hospitals with an ED in the State/Territory.

Using a scale of 0-5, please rate the degree to which your State/Territory has made towards establishing a recognition system for pediatric medical emergencies.

Element	0	1	2	3	4	5
1. Indicate the degree to which a facility recognition program for pediatric medical emergencies exists.

0= No progress has been made towards developing a statewide, territorial, or regional program that recognizes hospitals that are able to stabilize and/or manage pediatric medical emergencies

1= Research has been conducted on the effectiveness of a pediatric medical facility recognition program (i.e., improved pediatric outcomes)

And/or

Developing a pediatric medical facility recognition program has been discussed by the EMSC Advisory Committee and members are working on the issue.

2= Criteria that facilities must meet in order to receive recognition as being able to stabilize and/or manage pediatric medical emergencies have been developed.

3= An implementation process/plan for the pediatric medical facility recognition program has been developed. 4= The implementation process/plan for the pediatric medical facility recognition program has been piloted.

5= At least one facility has been formally recognized through the pediatric medical facility recognition program

EMSC 05 PERFORMANCE MEASURE Goal: Standardized System for Pediatric Trauma Level: Grantee Domain: Emergency Medical Services for Children	The percent of hospitals with an Emergency Department (ED) recognized through a statewide, territorial or regional standardized system that are able to stabilize and/or manage pediatric trauma.
GOAL	By 2022: 50% of hospitals are recognized as part of a statewide, territorial, or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric trauma.
MEASURE	The percent of hospitals recognized through a statewide, territorial or regional standardized system that are able to stabilize and/or manage pediatric traumatic emergencies.
DEFINITION	Numerator: Number of hospitals with an ED that are recognized through a statewide, territorial or regional standardized system that are able to stabilize and/or manage pediatric trauma. Denominator: Total number of hospitals with an ED in the State/Territory. Units: 100 Text: Percent Standardized system: A system of care provides a framework for collaboration across agencies, health care organizations/services, families, and youths for the purposes of improving access and expanding coordinated culturally and linguistically competent care for children and youth. The system is coordinated, accountable and includes a facility recognition program for pediatric traumatic injuries. Recognizing the pediatric emergency care capabilities of hospitals supports the development of a system of care that is responsive to the needs of children and extends access to specialty resources when needed. Hospital: Facilities that provide definitive medical and/or surgical assessment, diagnoses, and life and/or limb saving interventions for the ill and injured AND have an Emergency Department. Excludes Military and Indian Health Service hospitals.
EMSC STRATEGIC OBJECTIVE	Ensure the operational capacity and infrastructure to provide pediatric emergency care. Develop a statewide, territorial, or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric medical emergencies and trauma.
GRANTEE DATA SOURCES	This performance measure will require grantees to determine how many hospitals participate in their facility recognition program (if the state has a facility recognition program) for pediatric trauma.
SIGNIFICANCE	The performance measure emphasizes the importance of the existence of a standardized statewide, territorial, or regional system of care for children that includes a recognition program for hospitals capable of stabilizing and/or managing pediatric trauma emergencies. A standardized recognition and/or designation program, based on compliance with the current published pediatric emergency/trauma care guidelines, contributes to the development of an organized system of care that assists hospitals in determining their capacity and readiness to effectively deliver pediatric emergency/trauma and specialty care. This measure addresses the development of a pediatric trauma recognition program. Recognition programs are based upon State-defined criteria and/or adoption of national current published pediatric emergency and trauma care consensus guidelines that address administration and coordination of pediatric care; the qualifications of physicians, nurses and other ED staff; a formal pediatric quality improvement or monitoring program; patient safety; policies, procedures, and protocols; and the availability of pediatric equipment, supplies and medications. Additionally, EMSC 05 does not require that the recognition program be mandated. Voluntary facility recognition is accepted. However, the preferred status is to have a program that is monitored by the State/Territory.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 05

The percent of hospitals with an Emergency Department (ED) recognized through a statewide, territorial or regional standardized system that are able to stabilize and/or manage pediatric traumatic emergencies.

Numerator:
Denominator:
Percent

Numerator: Number of hospitals with an ED recognized through a statewide, territorial or regional standardized system that have been validated/designated as being capable of stabilizing and/or managing pediatric trauma patients.

Denominator: Total number of hospitals with an ED in the State/Territory.

Using a scale of 0-5, please rate the degree to which your State/Territory has made towards establishing a recognition system for pediatric traumatic emergencies.

Element	0	1	2	3	4	5
1. Indicate the degree to which a standardized system for pediatric traumatic emergencies exists.

0= No progress has been made towards developing a statewide, territorial, or regional system that recognizes hospitals that are able to stabilize and/or manage pediatric trauma emergencies

1= Research has been conducted on the effectiveness of a pediatric trauma facility recognition program (i.e., improved pediatric outcomes)

And/or

Developing a pediatric trauma facility recognition program has been discussed by the EMSC Advisory Committee and members are working on the issue.

2= Criteria that facilities must meet in order to receive recognition as a pediatric trauma facility have been developed.

3= An implementation process/plan for the pediatric trauma facility recognition program has been developed. 4= The implementation process/plan for the pediatric trauma facility recognition program has been piloted.

5= At least one facility has been formally recognized through the pediatric trauma facility recognition program

EMSC 06 PERFORMANCE MEASURE Goal: Inter-facility transfer guidelines Level: Grantee Domain: Emergency Medical Services for Children	The percent of hospitals with an Emergency Department (ED) in the State/Territory that have written inter-facility transfer guidelines that cover pediatric patients and that contain all the components as per the implementation manual.
GOAL	By 2021: 90% of hospitals in the State/Territory have written inter-facility transfer guidelines that cover pediatric patients and that include specific components of transfer.
MEASURE	The percentage of hospitals in the State/Territory that have written inter-facility transfer guidelines that cover pediatric patients and that include the following components of transfer: Defined process for initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer and communication). Process for selecting the appropriate care facility. Process for selecting the appropriately staffed transport service to match the patient’s acuity level (level of care required by patient, equipment needed in transport, etc.). Process for patient transfer (including obtaining informed consent). Plan for transfer of patient medical record Plan for transfer of copy of signed transport consent Plan for transfer of personal belongings of the patient Plan for provision of directions and referral institution information to family
DEFINITION	Numerator: Number of hospitals with an ED that have written inter- facility transfer guidelines that cover pediatric patients and that include specific components of transfer according to the data collected. Denominator: Total number of hospitals with an ED that provided data. Units: 100 Text: Percent Pediatric: Any person 0 to 18 years of age. Inter-facility transfer guidelines: Hospital-to-hospital, including out of State/Territory, guidelines that outline procedural and administrative policies for transferring critically ill patients to facilities that provide specialized pediatric care, or pediatric services not available at the referring facility. Inter-facility guidelines do not have to specify transfers of pediatric patients only. A guideline that applies to all patients or patients of all ages would suffice, as long as it is not written only for adults. Grantees should consult the EMSC Program representative if they have questions regarding guideline inclusion of pediatric patients. In addition, hospitals may have one document that comprises both the inter- facility transfer guideline and agreement. This is acceptable as long as the document meets the definitions for pediatric inter-facility transfer guidelines and agreements (i.e., the document contains all components of transfer). All hospitals in the State/Territory should have guidelines to transfer to a facility capable of providing pediatric services not available at the referring facility. If a facility cannot provide a particular type of care (e.g., burn care), then it also should have transfer guidelines in place. Consult the NRC to ensure that the facility (facilities) providing the highest level of care in the state/territory is capable of definitive care for all pediatric needs. Also, note that being in compliance with EMTALA does not constitute having inter-facility transfer guidelines. Hospital: Facilities that provide definitive medical and/or surgical assessment, diagnoses, and life and/or limb saving interventions for the ill and injured AND have an Emergency Department (ED). Excludes Military and Indian Health Service hospitals.
EMSC STRATEGIC OBJECTIVE	Ensure the operational capacity and infrastructure to provide pediatric emergency care Develop written pediatric inter-facility transfer guidelines for hospitals.
GRANTEE DATA SOURCE(S)	Surveys of hospitals with an emergency department. Hospital licensure rules and regulations
SIGNIFICANCE	In order to assure that children receive optimal care, timely transfer to a specialty care center is essential. Such transfers are better coordinated through the presence of inter-facility transfer agreements and guidelines.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 06

Performance Measure EMSC 06: The percentage of hospitals in the State/Territory that have written inter-facility transfer guidelines that cover pediatric patients and that include the following components of transfer:

• Defined process for initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer and communication).

• Process for selecting the appropriate care facility.

• Process for selecting the appropriately staffed transport service to match the patient’s acuity level (level of care required by patient, equipment needed in transport, etc.).

• Process for patient transfer (including obtaining informed consent).

• Plan for transfer of patient medical record

• Plan for transfer of copy of signed transport consent

• Plan for transfer of personal belongings of the patient

• Plan for provision of directions and referral institution information to family

Hospitals with Inter-facility Transfer Guidelines that Cover Pediatric Patients:

You will be asked to enter a numerator and a denominator, not a percentage. NOTE: This measure only applies to hospitals with an Emergency Department (ED).

NUMERATOR:

Number of hospitals with an ED that have written inter-facility transfer guidelines that cover pediatric patients and that include specific components of transfer according to the data collected.

DENOMINATOR:

Total number of hospitals with an ED that provided data.

EMSC 07 PERFORMANCE MEASURE Goal: Inter-facility Transfer Agreements Level: Grantee Domain: Emergency Medical Services for Children	The percent of hospitals with an Emergency Department (ED) in the State/Territory that have written inter-facility transfer agreements that cover pediatric patients.
GOAL	By 2021: 90% of hospitals in the State/Territory have written inter-facility transfer agreements that cover pediatric patients.
MEASURE	The percentage of hospitals in the State/Territory that have written inter-facility transfer agreements that cover pediatric patients.
DEFINITION	Numerator: Number of hospitals with an ED that have written inter- facility transfer agreements that cover pediatric patients according to the data collected. Denominator: Total number of hospitals with an ED that provided data. Units: 100 Text: Percent Pediatric: Any person 0 to 18 years of age. Inter-facility transfer agreements: Written contracts between a referring facility (e.g., community hospital) and a specialized pediatric center or facility with a higher level of care and the appropriate resources to provide needed care required by the child. The agreements must formalize arrangements for consultation and transport of a pediatric patient to the higher-level care facility. Inter-facility agreements do not have to specify transfers of pediatric patients only. An agreement that applies to all patients or patients of all ages would suffice, as long as it is not written ONLY for adults. Grantees should consult the NRC if they have questions regarding inclusion of pediatric patients in established agreements.
EMSC STRATEGIC OBJECTIVE	Ensure the operational capacity and infrastructure to provide pediatric emergency care. Develop written pediatric inter-facility transfer agreements to facilitate timely movement of children to appropriate facilities.
DATA SOURCE(S) AND ISSUES	Surveys of hospitals with an emergency department. Hospital licensure rules and regulations
SIGNIFICANCE	In order to assure that children receive optimal care, timely transfer to a specialty care center is essential. Such transfers are better coordinated through the presence of inter-facility transfer agreements and guidelines.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 07

Performance Measure EMSC 07: The percentage of hospitals in the State/Territory that have written inter-facility transfer agreements that cover pediatric patients.

Hospitals with Inter-facility Transfer Agreements that Cover Pediatric Patients:

You will be asked to enter a numerator and a denominator, not a percentage.

NOTE: This measure only applies to hospitals with an Emergency Department (ED).

NUMERATOR:

Number of hospitals with an ED that have written inter-facility transfer agreements that cover pediatric patients according to the data collected.

DENOMINATOR:

Total number of hospitals with an ED that provided data.

EMSC 08 PERFORMANCE MEASURE Goal: EMSC Permanence Level: Grantee Domain: Emergency Medical Service for Children	The degree to which the State/Territory has established permanence of EMSC in the State/Territory EMS system.
GOAL	To increase the number of States/Territories that have established permanence of EMSC in the State/Territory EMS system.
MEASURE	The degree to which States/Territories have established permanence of EMSC in the State/Territory EMS system.
DEFINITION	Permanence of EMSC in a State/Territory EMS system is defined as: The EMSC Advisory Committee has the required members as per the implementation manual. The EMSC Advisory Committee meets at least four times a year. Pediatric representation incorporated on the State/Territory EMS Board. The State/Territory require pediatric representation on the EMS Board. One full time EMSC Manager is dedicated solely to the EMSC Program. EMSC The component of emergency medical care that addresses the infant, child, and adolescent needs, and the Program that strives to ensure the establishment and permanence of that component. EMSC includes emergent at the scene care as well as care received in the emergency department, surgical care, intensive care, long-term care, and rehabilitative care. EMSC extends far beyond these areas yet for the purposes of this manual this will be the extent currently being sought and reviewed. EMS system The continuum of patient care from prevention to rehabilitation, including pre-hospital, dispatch communications, out-of-hospital, hospital, primary care, emergency care, inpatient, and medical home. It encompasses every injury and illness
EMSC STRATEGIC OBJECTIVE	Establish permanence of EMSC in each State/Territory EMS system. Establish an EMSC Advisory Committee within each State/Territory Incorporate pediatric representation on the State/Territory EMS Board Establish one full-time equivalent EMSC manager that is dedicated solely to the EMSC Program.
GRANTEE DATA SOURCES	Attached data collection form to be completed by grantee.
SIGNIFICANCE	Establishing permanence of EMSC in the State/Territory EMS system is important for building the infrastructure of the EMSC Program and is fundamental to its success. For the EMSC Program to be sustained in the long-term and reach permanence, it is important to establish an EMSC Advisory Committee to ensure that the priorities of the EMSC Program are addressed. It is also important to establish one full time equivalent EMSC Manager whose time is devoted solely (i.e., 100%) to the EMSC Program. Moreover, by ensuring pediatric representation on the State/Territory EMS Board, pediatric issues will more likely be addressed.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 08

Please indicate the elements that your grant program has established to promote permanence of EMSC in the State/Territory EMS system.

Element	Yes	No
1. The EMSC Advisory Committee has the required members as per the implementation manual.
2. The EMSC Advisory Committee has met four or more times during the grant year.
3. There is pediatric representation on the EMS Board.
4. There is a State/Territory mandate requiring pediatric representation on the EMS Board.
5. There is one full-time EMSC Manager that is dedicated solely to the EMSC Program.

Yes = 1

No = 0

Total number of elements your grant program has established (possible 0-5 score)

EMSC 09 PERFORMANCE MEASURE Goal: Integration of EMSC priorities Level: Grantee Domain: Emergency Medical Services for Children	The degree to which the State/Territory has established permanence of EMSC in the State/Territory EMS system by integrating EMSC priorities into statutes/regulations.
GOAL	By 2027, EMSC priorities will have been integrated into existing EMS or hospital/healthcare facility statutes/regulations.
MEASURE	The degree to which the State/Territory has established permanence of EMSC in the State/Territory EMS system by integrating EMSC priorities into statutes/regulations.
DEFINITION	Priorities: The priorities of the EMSC Program include the following: EMS agencies are required to submit NEMSIS compliant data to the State EMS Office. EMS agencies in the state/territory have a designated individual who coordinates pediatric emergency are. EMS agencies in the state/territory have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment. The existence of a statewide, territorial, or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric medical emergencies trauma (continued on next page)
DEFINITION (continued)	Hospitals in the State/Territory have written inter- facility transfer guidelines that cover pediatric patients and that include the following components of transfer: Defined process for initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer and communication). Process for selecting the appropriate care facility. Process for selecting the appropriately staffed transport service to match the patient’s acuity level (level of care required by patient, equipment needed in transport, etc.). Process for patient transfer (including obtaining informed consent). Plan for transfer of patient medical record Plan for transfer of copy of signed transport consent Plan for transfer of personal belongings of the patient Plan for provision of directions and referral institution information to family Hospitals in the State/Territory have written inter-facility transfer agreements that cover pediatric patients. BLS and ALS pre-hospital provider agencies in the State/Territory are required to have on-line and off-line pediatric medical direction available. BLS and ALS patient care units in the State/Territory have the essential pediatric equipment and supplies, as outlined in the nationally recognized and endorsed guidelines. Requirements adopted by the State/Territory that requires pediatric continuing education prior to the renewal of BLS/ALS licensing/certification.
EMSC STRATEGIC OBJECTIVE	Establish permanence of EMSC in each State/Territory EMS system.
GRANTEE DATA SOURCES	Attached data collection form to be completed by grantee.
SIGNIFICANCE	For the EMSC Program to be sustained in the long-term and reach permanence, it is important for the Program’s priorities to be integrated into existing State/Territory mandates. Integration of the EMSC priorities into mandates will help ensure pediatric emergency care issues and/or deficiencies are being addressed State/Territory-wide for the long-term.

DATA COLLECTION FORM FOR DETAIL SHEET: EMSC 09

Please indicate the elements that your grant program has established to promote the permanence of EMSC in the State/Territory EMS system by integrating EMSC priorities into statutes/regulations.

Element	Yes	No
1. There is a statute/regulation that requires the submission of NEMSIS compliant data to the state EMS office
2. There is a statute/regulation that assures an individual is designated to coordinate pediatric emergency care.
3. There is a statute/regulation that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment.
4. There is a statute/regulation for a hospital recognition program for identifying hospitals capable of dealing with pediatric medical emergencies.
5. There is a statute/regulation for a hospital recognition system for identifying hospitals capable of dealing with pediatric traumatic emergencies.
6. There is a statute/regulation for written inter-facility transfer guidelines that cover pediatric patients and include specific components of transfer.
7. There is a statute/regulation for written inter-facility transfer agreements that cover pediatric patients.
8. There is a statute/regulation for pediatric on-line medical direction for ALS and BLS pre-hospital provider agencies.
There is a statute/regulation for pediatric off-line medical direction for ALS and BLS pre-hospital provider agencies.
There is a statute/regulation for pediatric equipment for BLS and ALS patient care units.
There is a statute/regulation for the adoption of requirements for continuing pediatric education piror to recertification/relicensing of BLS and ALS providers.

Yes = 1

No = 0

Total number of elements your grant program has established (possible 0-11 score)

DIVISION OF HEALTHY START AND PERINATAL SERVICES

PERFORMANCE MEASURE DETAIL SHEET SUMMARY TABLE

Performance Measure	New/Revised Measure	Prior PM Number (if applicable)	Topic
HS 01	New		Reproductive Life Plan
HS 02	Revised	17, 20	Usual Source of Care
HS 03	New		Interconception Planning
HS 04	New		Early Elective Delivery
HS 05	New		Intimate Partner Violence Screening
HS 06	New		Father/ Partner Involvement during Pregnancy
HS 07	New		Father and/or Partner Involvement with Child 0-24 Months
HS 08	New		Daily Reading
HS 09	New		CAN implementation
HS 10	New		CAN Participation

HS 01 PERFORMANCE MEASURE Goal: Reproductive Life Plan Level: Grantee Domain: Healthy Start	The percent of Healthy Start participants that have a documented reproductive life plan.
GOAL	To increase the proportion of Healthy Start women participants who have a documented reproductive life plan to 90%.
MEASURE	The percent of Healthy Start women participants that have a documented reproductive life plan.
DEFINITION	Numerator: Number of Healthy Start (HS) women participants with a documented reproductive life plan. Denominator: Number of HS women participants. There is no formal written format for a reproductive life plan. A participant is considered to have a reproductive life plan and included in the numerator if there is documentation in the participant’s record of an annually updated statement to include: 1) goals for having or not having children; and 2) plans for how to achieve those goals. Participants with permanent birth control are included in both the denominator and numerator.
BENCHMARK DATA SOURCES
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	A reproductive life plan reduces the risk of unintended pregnancy, identifies unmet reproductive health care needs, and increases the number of women who plan their pregnancies and engage in healthy behaviors before becoming pregnant.1

HS 02 PERFORMANCE MEASURE Goal: Usual Source of Care Level: Grantee Domain: Healthy Start	The percent of Healthy Start women and child participants that have a usual source of care.
GOAL	To increase the percent of Healthy Start women and child participants who have a usual source of care to 80%.
MEASURE	The percent of Healthy Start women and child participants that have a usual source of care.
DEFINITION	Numerator: number of Healthy Start (HS) women and child participants that have a usual source of primary care as of their last HS contact. Denominator: Total number of women and child HS participants. A participant is considered to have a medical home and included in the numerator if the participant has a usual source of care. That is, the participant identifies a regular place where she or her child can go for routine and sick care other than an emergency room. A participant receiving regular prenatal care from a prenatal provider is considered to have a medical home.
BENCHMARK DATA SOURCES	Kaiser Family Foundation 2011(Children with a Medical Home 54.4%, 2011), Kaiser Family Foundation 2013 (Adults without a Personal Doctor 23.7%, 2013), National Survey of Children’s Health (Children with Medical Home 54.4%, 2011-2012)
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	A medical home reduces overall costs to patients, employers, and health plans by reducing emergency department visits, hospital readmissions, and inpatient visits. The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. As medical home implementation increases, overall health costs are decreasing and quality of health care is increasing. 2

HS 03 PERFORMANCE MEASURE Goal: Interconception Planning Level: Grantee Domain: Healthy Start	The percent of Healthy Start women participants who conceive within 18 months of a previous birth.
GOAL	To reduce the proportion of Healthy Start women participants who conceive within 18 months of a previous birth to 30%.
MEASURE	The percent of Healthy Start women participants who conceive within 18 months of a previous birth.
DEFINITION	Numerator: Number of Healthy Start (HS) women participants whose current pregnancy was conceived within 18 months of the previous birth. Denominator: Total number of HS women participants enrolled before the current pregnancy who had a prior pregnancy. The interval between the most recent pregnancy and previous birth is derived from the delivery date of the birth and the date of conception for the most recent pregnancy. 18 month spacing of pregnancies applies to both live births.
BENCHMARK DATA SOURCES	CDC National Survey of Family Growth, Healthy People 2020 Family Planning Goal 5. Numerator, denominator, and definition match the CDC NSFG which also aligns with HP 2020 Family Planning Goal 5.
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	Family planning is important to ensure spacing pregnancies at least 18 months apart to reduce health risks for both mother and baby. Pregnancy within 18 months of giving birth is associated with increased risk for the baby including low birth weight, small size for gestational age, and preterm birth. Additionally, the mother needs time to fully recovering from the previous birth.3.

HS 04 PERFORMANCE MEASURE Goal: Early Elective Delivery Level: Grantee Domain: Healthy Start	The percent of Healthy Start women participants with elective delivery before 39 weeks.
GOAL	To reduce the proportion of Healthy Start women participants with elective delivery before 39 weeks to 10%.
MEASURE	The percent of Healthy Start women participants with elective delivery before 39 weeks.
DEFINITION	Numerator: Number of Healthy Start (HS) prenatal participants with elective delivery (i.e., exclude medically necessary delivery) before 39 weeks. Denominator: Total number of HS prenatal participants enrolled prenatally who gave birth. A participant is included in the denominator if she is enrolled in the program prior to delivering. Exclude women who are enrolled at delivery from the denominator. An elective delivery is performed for a nonmedical reason. Some reasons include wanting to schedule the birth of the baby on a specific date or living far away from the hospital. Some women request delivery because they are uncomfortable in their last weeks of pregnancy or request a cesarean delivery because they may fear vaginal birth. Medically indicated delivery is done for medical reasons. These reasons may include the woman’s medical condition or problems with fetal development. Labor may be induced or a cesarean delivery may be performed.4
BENCHMARK DATA SOURCES
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	Babies who are born before 39 weeks may not be as developed as those who are born at a full term of 40 weeks. Because the baby may be underdeveloped, they may have an increased risk of short-term and long-term health problems. 5

HS 05 PERFORMANCE MEASURE Goal: Intimate Partner Violence Screening Level: Grantee Domain: Healthy Start	The percent of HS women participants who receive intimate partner violence screening.
GOAL	To increase proportion of Healthy Start women participants who receive intimate partner violence (IPV) screening to 100%.
MEASURE	The percent of Healthy Start women participants who receive intimate partner violence screening.
DEFINITION	Numerator: Number of Healthy Start (HS) women participants who received intimate partner violence screening using a standardized screening tool during the reporting year. Denominator: Total number of HS women participants. A participant is considered to have been screened and included in the denominator if a standardized screening tool which is appropriately validated for her circumstances is used. A number of screening tools have been validated for IPV screening. Intimate Partner Violence is a pattern of assaultive behavior and coercive behavior that may include physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion. These behaviors are committed by someone who is, was, or wishes to be involved in an intimate relationship with the participant.6
BENCHMARK DATA SOURCES	US DHHS ASPE, ACOG
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	Intimate Partner Violence is a substantial yet preventable public health problem that affects women across the world. Research shows that intimate partner violence screening differs among health care specialties and is overall relatively low. The U.S. Department of Health and Human Services recommends that IPV screening and counseling to be a core part of a women’s well visit. 7

HS 06 PERFORMANCE MEASURE Goal: Father/ Partner Involvement during pregnancy Level: Grantee Domain: Healthy Start	The percent of Healthy Start women participants that demonstrate father and/or partner involvement during pregnancy.
GOAL	To increase proportion of Healthy Start women participants that demonstrate father and/or partner involvement (e.g., attend appointments, classes, etc.) to 90%.
MEASURE	The percent of Healthy Start women participants that demonstrate father and/or partner involvement during pregnancy.
DEFINITION	Numerator: Number of Healthy Start (HS) prenatal participants who report supportive father and/or partner involvement (e.g., attend appointments, classes, etc.) as of last HS contact. Denominator: Total number HS prenatal participants. A participant is considered to have support and included in the numerator if she self- reports a partner who has a significant and positive role in the participant’s pregnancy. Involvement during pregnancy may include, but is not limited to: Attending prenatal appointments Attending prenatal classes Assisting in preparing the home for the baby e.g,, putting together a crib Providing economic support
BENCHMARK DATA SOURCES	Child Trend Research Brief, CDC National Health Statistics Report
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	Research suggests that paternal involvement has been recognized to have an impact on both pregnancy and infant outcomes. Father involvement during pregnancy has shown to reduce negative maternal health behaviors, risk of preterm birth, low birth weight, and fetal growth restrictions.

HS 07 PERFORMANCE MEASURE Goal: Father and/or Partner Involvement with child 0-24 Months Level: Grantee Domain: Healthy Start	The percent of Healthy Start participants with father and/or partner involvement with child 0-24 months.
GOAL	To increase the proportion of HS grantees that demonstrate father and/or partner involvement (e.g., attend appointments, classes, infant/child care) with child 0-24 months to 80%).
MEASURE	The percent of Healthy Start participants with father and/or partner involvement with child 0-24 months.
DEFINITION	Numerator: Number of Healthy Start (HS) child participants whose mother reports supportive father and/or partner involvement (e.g., attend appointments, classes, child care, etc.) as of the last HS contact. Denominator: Total number child participants aged 0 to 24 months. A participant is considered to have support and included in the numerator if she self- reports a partner who has a significant and positive role for the child. Involvement includes, but is not limited to:8 Engagement or direct interaction with the child, including taking care of, playing with, or teaching the child Accessibility or availability, which includes monitoring behavior from the next room or nearby and allowing direct interaction if necessary Responsibility for the care of the child, which includes making plans and arrangements for care Economic support or breadwinning Attending postpartum and well child visits
BENCHMARK DATA SOURCES
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	Father and/or partner involvement should consider participation in areas of medical appointments for infants, children and/or mother, attending HS sponsored classes, prenatal care, care for infant or child, etc.

HS 08 PERFORMANCE MEASURE Goal: Daily Reading Level: Grantee Domain: Healthy Start	The percent of Healthy Start child participants aged 0-24 months who are read to 5 or more times per week, on average.
GOAL	To increase the proportion of Healthy Start child participants aged 0-24 months who are read to 5 or more times per week to 50%
MEASURE	The percent of Healthy Start child participants aged 0-24 months who are read to 5 or more times per week, on average.
DEFINITION	Numerator: Number of Healthy Start (HS) child participants who were read to 5 or more times a week, on average.9 Denominator: Total number of HS child participants age 0 to 24 months.
BENCHMARK DATA SOURCES	National Survey of Children’s Health (2011-2012)
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	Reading to a child teaches them about communication, introduces concepts such as numbers, letters, colors, and shapes, builds listening, memory, and vocabulary skills, and gives them information about the world around them. 10 The American Academy of Pediatrics (AAP) promotes reading aloud as a daily fun family activity to promote early literacy development as an important evidence-based intervention beginning in infancy and continuing at least until the age of school entry. 11

HS 09 PERFORMANCE MEASURE Goal: CAN implementation Level: Grantee Domain: Healthy Start	The percent of Healthy Start grantees with a fully implemented Community Action Network (CAN).
GOAL	To increase the proportion of HS grantees with a fully implemented Community Action Network (CAN) to 100%.
MEASURE	The percent of Healthy Start grantees with a fully implemented Community Action Network (CAN).
DEFINITION	Two benchmarks are calculated to capture Community Action Network (CAN) implementation and progress towards achieving collective impact: Numerator: Number of related CAN measure components implemented by the CAN in which the Healthy Start grantee participates. Denominator: 3 (representing total of CAN components) This is a scaled measure which reports progress towards full implementation of a CAN. A “yes” answer is scored 1 point; a “no” answer receives no point. To meet the standard of “fully implemented” for this measure, the HS grantee must answer “yes” to all three core elements listed below: 1. Does your CAN have regularly scheduled meetings? (Regular scheduled is minimally defined as every quarter during the reporting period). This can be documented by using sign in sheets. Yes = 1 No = 0 2. Does your CAN have members from three or more community sectors? (e.g., individuals with lived experience, Healthy Start consumer, faith based, hospital, school setting, community based organizations, government, business, medical provider(s), child care provider(s)). Yes = 1 No = 0 3. Does your CAN have a twelve month work plan? This work plan should outline the CAN’s goals, objectives, activities, entities responsible for completing, and timelines. Yes = 1 No = 0
	------------------------------------------------------------------------------------ Numerator: Number of related Collective Impact (CI) measure components implemented by the CAN in which the Healthy Start grantee participates. Denominator: 10 (representing total points for 5 CI measure components) This is a scaled measure which reports progress towards full implementation of Collective Impact. A “yes” answer is scored 2 points; “in process” is scored 1 point; a “no” answer receives no point. To meet the standard of “fully implemented” for this measure, the HS grantee must answer “yes” to all five core elements listed below:
	1. Does your CAN have a common agenda developed? All participants have a shared vision for change including a common understanding of the problem and a joint approach to solving it through agreed upon actions. This can be documented by using a theory of change, logic model, work plan template that captures this information, and/or a charter. Yes = 2 In Process = 1 Not started = 0 2. Does your CAN have Shared Measurement Systems? The CAN has identified a common set of indicators that tracks progress/action related to the common agenda, collects data across partners, presents data on a consistent basis, and uses data to make informed decisions and to hold each other accountable. Yes = 2 In Process = 1 Not started = 0 3. Does your CAN engage in Mutually Reinforcing Activities? Participant activities are differentiated while still being coordinated through a mutually reinforcing plan of action. This plan of action can be included on the work plan noted above and should include at least two to three activities, a description of how it is believed that the activities will impact the common agenda, how the activities will be measured, who/what organization will take the lead, and the timeline for implementation. Yes = 2 In Process = 1 Not started = 0 4. Does your CAN have Continuous Communication? Consistent and open communication is needed across the many players to build trust, assure mutual objectives, and appreciate common motivation. A communication plan agreed upon by stakeholders should be included as a part of the work plan noted above. Yes = 2 In Process = 1 Not started = 0 5. Does your CAN have a backbone infrastructure in place? Creating and managing collective impact requires a dedicated staff and a specific set of skills to serve as the backbone for the entire initiative and coordinate participating organizations and agencies. Documentation is shared with CAN members describing roles and responsibilities, and skills required for staff of the entity(ies) supporting the backbone infrastructure. Yes = 2 In Process = 1 Not started = 0
BENCHMARK DATA SOURCES
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	A Community Action Network, or CAN, is an existing, formally organized partnership of organizations and individuals. The CAN represents consumers and appropriate agencies which unite in an effort to collectively apply their resources to the implementation of one or more commons strategies to achieve a common goal within that project area.

HS 10 PERFORMANCE MEASURE Goal: CAN participation Level: Grantee Domain: Healthy Start	The percent of Healthy Start grantees with at least 25% community members and Healthy Start program participants serving as members of their CAN.
GOAL	To increase the proportion of Healthy Start grantees with at least 25% community members and Healthy Start program participants serving as members of their CAN to 100%.
MEASURE	The percent of Healthy Start grantees with at least 25% community members and Healthy Start program participants serving as members of their CAN.
DEFINITION	Numerator: Number of community members and Healthy Start (HS) program participants serving as members of the CAN. Denominator: Total number of individual members serving on the CAN. Community Member: an individual who has lived experience that is representative of the project’s Healthy Start target population. Community members may include former Healthy Start participants, fathers and/or partners of Healthy Start participants, males and family members. Program Participant: an individual having direct contact with Healthy Start staff or subcontractors and receiving Healthy Start services on an ongoing systematic basis to improve perinatal and infant health. Specifically, program participants are pregnant women and women of reproductive age and children up to age 2. A Community Action Network, or CAN, is an existing, formally organized partnership of organizations and individuals. The CAN represents consumers and appropriate agencies which unite in an effort to collectively apply their resources to the implementation of one or more commons strategies to achieve a common goal within that project area.
BENCHMARK DATA SOURCES
GRANTEE DATA SOURCES	Grantee data systems
SIGNIFICANCE	Consumer involvement in setting the community agenda and informing efforts to effectively meet the community’s needs is critical to the effectiveness of the CAN.

DIVISION OF CHILDREN WITH SPECIAL HEALTH NEEDS

Family to Family Health Information Center Program

PERFORMANCE MEASURE DETAIL SHEET SUMMARY TABLE

Performance Measure	New/Revised Measure	Previous Performance Measure Number	Topic
F2F 1	Revised	70	Provide National Leadership for families with children with special health needs

F2F 1 Performance Measure Goal: Provide National Leadership for families with children with special health needs Level: Grantee Category: Family Participation	The percent of families with Children with Special Health Care Needs (CSHCN) that have been provided information, education, and/or training by Family-to-Family Health Information Centers.
GOAL	To increase the number of families with CSHCN receiving needed health and related information, training, and/or education opportunities in order to partner in decision making and be satisfied with services that they receive.
MEASURE	The percent of families with CSHCN that have been provided information, education and/or training by Family-to-Family Health Information Centers.
DEFINITION	Numerator: The total number of families with CSHCN in the State that have been provided information, education, and/or training from Family-To-Family Health Information Centers.
	Denominator: The number of families that can be reasonably served with provided federal grant funds.
	Units: 100 Text: Percent
BENCHMARK DATA SOURCES	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
GRANTEE DATA SOURCES	Progress reports from Family-To-Family Health Care Information and Education Centers, National Survey for Children’s Health (NSCH), Title V Information System
SIGNIFICANCE	The last decade has emphasized the central role of families as informed consumers of services and participants in policy-making activities. Research has indicated that families need information they can understand and information from other parents who have experiences similar to theirs and who have navigated services systems.

DATA COLLECTION FORM FOR DETAIL SHEET #F2F 1

A. Providing Information, Education, and/or Training

The number of families that can be reasonably served with provided federal grant funds: _____________

1. The total number of families served is based solely on “one-to-one” service conducted by the F2F.

a. Total number of families served/trained: ___________

b. Of the total number of families served/trained, how many families identified themselves as

Ethnicity

1. Hispanic

2. Non-Hispanic

Race

1. White

2. Black or African American

3. Asian

4. Native Hawaiian or Pacific Islander

5. Native American/American Indian or Alaskan Native

6. Some other Race

7. Multiple races

8. Unknown

c. Total instances of service/training provided (this will be a duplicated count): ­­­­­­­­­_______________

d. Of the total instances of service, how many provided

1. Individualized assistance (Includes one-on-one instruction, consultation, counseling, case management, and mentoring) _____

2. Basic contact information and referrals ______

3. Group training opportunities ______

4. Meetings/Conferences and Public Events (includes outreach events and presentations) _______

e. Of the total number of families served/trained, how many instances of service related to the following issues:

1. Partnering/decision making with providers

Number of families served/trained _____

2. Accessing a medical home

Number of families served/trained _______

3. Financing for needed health services

Number of families served/trained _______

4. Early and continuous screening

Number of families served/trained ______

5. Navigating systems/accessing community services easily

Number of families served/trained _______

6. Adolescent transition issues

Number of families served/trained ______

7. Other (Specify): _____________________________________________

Number of families served/trained ______

2. Our organization provided health care information/education to professionals/providers to assist them in better providing services for CSHCN.

a. Total number of professionals/providers served/trained: ___________

b. Total instances of service/training provided (this will be a duplicated count): ­­­­­­­­­_______________

c. Of the total number of professionals/providers served/trained, how many instances of service were used to provide health care information/education related to the following issues:

1. Partnering/decision making with families

Number of professionals/providers served/trained: _____

2. Accessing/providing a medical home

Number of professionals/providers served/trained: _____

3. Financing for needed services

Number of professionals/providers served/trained: _____

4. Early and continuous screening

Number of professionals/providers served/trained: _____

5. Navigating systems/accessing community services easily

Number of professionals/providers served/trained: _____

6. Adolescent transition issues

Number of professionals/providers served/trained: _____

7. Other (Specify):_____________________________________________

Number of professionals/providers served/trained: ______

3. Our organization conducted communication and outreach to families and other appropriate entities through a variety of methods.

1. Select the modes of how print/media information and resources are disseminated. (Select all that apply).

   • Electronic newsletters and listservs

   • Hardcopy

   • Public television/radio

   • Social media (Specify platform): _________

   • Text messaging

4. Our organization worked with State agencies/programs to assist them with providing services to their populations and/or to obtain their information to better serve our families.

a. Types of State agencies/programs - Total: _________

b. Indicate the types of State agencies/programs with which your organization has worked:

1. State level Commissions, Task Forces, etc.

2. MCH/CSHCN

3. Genetics/newborn screening

4. Early Hearing Detection and Intervention/Newborn Hearing screening

5. Emergency Medical Services for Children

6. LEND Programs

7. Oral Health

8. NICHQ Learning Collaboratives

9. Developmental Disabilities

10. Medicaid (CMS),SCHIP

11. Private Insurers

12. Case Managers

13. SAMHSA/Mental & Behavioral Health

14. Federation of Families for Children’s Mental Health

15. HUD/housing

16. Early Intervention/Head Start

17. Education

18. Child Care

19. Juvenile Justice/Judicial System

20. Foster Care/Adoption agencies

21. Other (Specify): _______________________________________

22. None

B. MODELS of family engagement Collaboration

1. Our organization served/worked with community-based organizations to assist them with providing services to their populations and/or to obtain their information to better serve our families.

a. Types of community-based organizations - Total: _________

b. Indicate the types of community-based organizations with which your organization has worked:

• Other family organizations, groups

• Medical homes, providers, clinics

• Children’s hospitals

• American Academy of Pediatrics Chapter

• Hospitals - Residents, hospital staff training

• Hospitals - Other:____________________________

• Universities - Schools of Public Health

• Universities - Schools of Nursing

• Universities - Schools of Social Work

• Community Colleges

• Schools

• Interagency groups

• Faith-based organizations, places of worship

• Non-Profits, such as United Cerebral Palsy, March of Dimes, etc)

• Ethnic/racial specific organizations

• Community Teams

• Other (Specify): _____________________________

• None

2. Family-to-Family Health Information Center goals/objectives were accomplished through formal and informal partnership strategies and practices.

1. Number of agreements with partners (from partners identified in items 3 and 4). Total _______

2. Indicate the type of partnership agreements that were in place during the reporting period:

• Subcontract

• Memorandum of Understanding/Agreement

• Letter of Invitation/Acceptance/Support

• Informal/Verbal Arrangement

• Other (Specify): ______________________

9. Our organization is staffed by families with expertise in Federal and State public and private health care systems.

1. Number of Family-to-Family FTE _______

2. Number of FTE who are family/have a disability _____

1 http://www.cdc.gov/preconception/documents/reproductivelifeplan-worksheet.pdf

2 https://www.pcpcc.org/guide/benefits-implementing-primary-care-medical-home

3 http://www.mayoclinic.org/healthy-lifestyle/getting-pregnant/in-depth/family-planning/art-20044072

4 http://www.acog.org/Patients/FAQs/Elective-Delivery-Before-39-Weeks

5 http://www.acog.org/Patients/FAQs/Elective-Delivery-Before-39-Weeks

6 http://mchb.hrsa.gov/whusa09/hstat/hi/pages/226ipv.html

7 http://aspe.hhs.gov/report/screening-domestic-violence-health-care-settings/prevalence-screening

8 http://www.cdc.gov/nchs/data/nhsr/nhsr071.pdf

9 http://www.childhealthdata.org/browse/survey/results?q=2284&r=1&g=458. Note: Children’s Health Survey separates the measure by # of days read.

10 http://kidshealth.org/parent/positive/all_reading/reading_babies.html

11 http://pediatrics.aappublications.org/content/pediatrics/134/2/404.full.pdf

Attachment B | 23