Form E E. NHSPS Survey_revised

Attachment E

National Healthy Start Program Survey

National Healthy Start Program Survey

03.05.2014

ADMINISTRATIVE NOTES:

• The instrument is designed in a self-administered web format, estimated at 2 hours in length.

• Prior to each item, the universe of who among the survey respondents is to complete the item is specified in the boxed, gray bar. Skip patterns, where applicable, will be specified next to response options. This information will not be shown to the survey respondents but is presented here to display the skip logic and universe of respondents for each question.

• The survey will be deployed in English only.

• Text fills, noted in this instrument with use of brackets and text in all caps [FILL] are assumed as follows:

[GRANT YEAR] = Year prior to deploying survey

[ORG NAME] = Healthy Start Project name filled from sample file

[CAN MEMBER] = Names of community action network (CAN) members filled from sample file

• For the items containing green highlighting, only some responses will be displayed on the screen based on the respondents’ response to an earlier question. The green highlighted text will not be visible to respondents but is presented here to display the programming logic for these questions.

• Question source is listed in parenthesis at the end of each survey item. Items without a source listed are new items that were created for the purpose of this survey. Question source will not be visible to survey respondents. Sources are abbreviated in the survey as follows:

NHSPS = Previous National Healthy Start Program Survey

CVC Survey = Community Voices for Coverage Leadership Team Follow-Up Survey

Wilder = Wilder Collaboration Factors Inventory

Living Cities = Living Cities TII Grantee-Partner Network Survey

SHAPE 2002 = Survey of the Health of Adults, the Population and the Environment 2002

SOCAT Household = Social Capital Assessment Tool Household Survey

SOCAT Community = Social Capital Assessment Tool Community Questionnaire

• Items that allow multiple responses have the instruction to “Select all that apply,” and items allowing only a single response have the instruction to “select only one.”

INTRODUCTION AND INSTRUCTIONS FOR RESPONDENTS:

The National Healthy Start Project Survey

Welcome!

Healthy Start has produced a tremendous amount of national interest as a means of reducing disparities in infant mortality and improve perinatal outcomes in the United States. It is critical to obtain your input on the experiences of your Healthy Start project, because it will enable us to

• Evaluate grantees’ performance and progress toward achieving goals and outcomes of the National Healthy Start Program;

• Provide information about the implementation of the program to help identify best and promising practices for dissemination and replication; and

• Assist the Maternal Child and Health Bureau (MCHB) in determining, on a national level, where technical assistance may be needed to improve program performance, set future priorities for program activities, and contribute to the overall strategic planning activities of MCHB.

This survey should take approximately two hours to complete. The information we obtain will be used for research purposes only. All of the information you provide will be kept confidential to the extent allowed by law. You do not have to answer any question you do not want to, and you can end the survey at any time. The evaluation will not identify individuals or organizations in its reports to MCHB.

The table below shows the sections of the survey and the questions in each section.

	SECTION	QUESTIONS
1	OVERVIEW OF SERVICES, STAFFING, OUTREACH, AND RETENTION
1a	Background	1.1–1.7
1b	Outreach and Recruitment	1.8–1.9
1c	Services	1.10–1.11
1d	Staffing	1.12–1.13
1e	Retention	1.14–1.16
2	IMPROVE WOMEN’S HEALTH
2a	Comprehensive Assessment	2.1–2.5
2b	Case Management	2.6–2.17
2c	Health Insurance Enrollment Services	2.18–2.28
2d	Support for Prevention	2.29–2.37
3	PROMOTE QUALITY SERVICES
3a	Service Coordination and Medical Home	3.1–3.17
3b	Other Standardized Curricula/Home Visiting	3.18–3.28
3c	Cultural and Linguistic Competence	3.29–3.32
3d	Focus on Prevention and Health Promotion	3.33–3.55
4	STRENGTHEN FAMILY RESILIENCE
4a	Support Mental and Behavioral Health	4.1–4.6
4b	Trauma Informed Care	4.7–4.13
4c	Promote Family and Father Involvement	4.14–4.26
4d	Improve Parenting	4.27–4.30
5	ACHIEVE COLLECTIVE IMPACT
5a	Develop and Use Community Action Network	5.1–5.17
5b	Community Social Capital and Empowerment	5.18–5.19
5c	Strategic Action Plan	5.20–5.23
5d	Community Empowerment	5.24
5e	Partnerships	5.25–5.32
6	INCREASE ACCOUNTABILITY THROUGH QUALITY IMPROVEMENT, PERFORMANCE MONITORING, AND EVALUATION
6a	Quality Improvement	6.1–6.7
6b	Performance Monitoring	6.8–6.18
6c	Evaluation	6.19–6.25
6d	Healthy Start Project Achievements	6.26-6.28

Instructions:

1. Answer the questions by clicking your mouse on the appropriate box.

2. Once you have answered the questions on one page, click the “next” button at the bottom of the page to continue. To go back to a previous page, click the “back” button.

3. If you need to stop, you can log out of the survey by closing your browser. You can return to the survey later by clicking on the link in your email.

When you reenter the survey, your previous answers will be saved. You also will be able to change your previous answers, if necessary.

Please complete the survey by [DATE]. If you have any questions about the survey, please contact [NAME] via email [EMAIL] or by telephone at [TELEPHONE NUMBER].

SECTION 1. OVERVIEW OF SERVICES, STAFFING, OUTREACH, AND RETENTION

The first section asks general questions about your Healthy Start project, including the specific services your project offers, how your project recruits and retains participants, and how your project is staffed.

1a. BACKGROUND

All

1.1. What is the local name for your Healthy Start project?

(STRING 1000)

NO RESPONSE M

all

1.2. How would you classify the community in which your Healthy Start project operates?

Select one only.

 Rural 1

 Urban 2

 Border community 3

NO RESPONSE M

all

1.3. How many site locations does your Healthy Start project have? Please include locations where Healthy Start paid staff are located, counting contractor locations.

Number of locations

(RANGE 0–100)

NO RESPONSE M

all

1.4a. How would you classify the entity that has direct fiduciary and administrative responsibility over your Healthy Start project?

Select all that apply

 Community health center 1

 Community-based organization 2

 Faith-based organization 3

 Hospital-based clinic 4

 Indian tribe or tribal organization 5

 Local health department 6

 Other 99

Specify (STRING 1000)

NO RESPONSE M

all

1.4b. In which of the following types of places does your Healthy Start project operate?

Select all that apply

 Community health center 1

 Community-based organization 2

 Faith-based organization 3

 Hospital-based clinic 4

 Indian tribe or tribal organization 5

 Local health department 6

 Other 99

Specify (STRING 1000)

NO RESPONSE M

all

1.5. During [GRANT YEAR], how many women did your Healthy Start project serve?

Please include preconceptional/interconceptional and pregnant women that received direct services. Do not include community participants—that is, an individual who attends a Healthy Start–sponsored event or participates in community action network (CAN) activities.

Total number of women

(RANGE 0–1000)

NO RESPONSE M

IF PROGRAM LEVEL = 1, CHECK THAT 1.5 >= 500

IF PROGRAM LEVEL = 2, CHECK THAT 1.5 >= 800

IF PROGRAM LEVEL = 3, CHECK THAT 1.5 >= 1000

all

1.6. During [GRANT YEAR], how many children did your Healthy Start project serve? Include children up to the age of 2 that received Healthy Start direct services.

Total number of children

(RANGE 0–5000)

NO RESPONSE M

all

1.7. During [GRANT YEAR], how many participants enrolled in Healthy Start when they were preconceptional/ interconceptional and pregnant? Your best estimate is fine.

A program participant is defined as 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.

Preconceptional/interconceptional women are those that have never been pregnant or are between pregnancies.

	Number of Participating Women in Stage	Total Number of Participating Women	Row Percent	No Response
a. Preconceptional/interconceptional		FILL 1.6a	FILL %	M
b. Pregnant		FILL 1.6a	FILL %	M
Total			100

1b. OUTREACH AND RECRUITMENT

The next questions are about the ways that your Healthy Start project recruits participants.

all

1.8. What mass media strategies does your Healthy Start project use to conduct outreach and recruit participants? (NHSPS 1.6b modified)

Mass media strategies include all forms of public communication aimed at reaching a large audience.

Select one per row.

	Yes	No	No Response
a. Brochures/fliers/mailings	1 	2 	M
b. Internet advertising/social media	1 	2 	M
c. Newspaper/print advertising (ads, articles)	1 	2 	M
d. Poster/billboards	1 	2 	M
e. Radio (ads, PSAs, talk shows)	1 	2 	M
f. TV (ads, PSAs, talk shows)	1 	2 	M
g. Other mass media strategies (specify):________________________________	1 	2 	M

all

1.9. What community-based strategies does your Healthy Start project use to conduct outreach and participant recruitment? (NHSPS 1.5b modified)

Select one per row.

	Yes	No	No Response
a. Attend community events like health fairs	1 	2 	M
b. Canvas neighborhoods or community settings	1 	2 	M
c. Conduct classes or make presentations to local groups	1 	2 	M
d. Network with health care providers, schools, or other agencies	1 	2 	M
e. Operate hotline	1 	2 	M
f. Organize community events	1 	2 	M
g. Referrals from other providers	1 	2 	M
h. Word of mouth	1 	2 	M
i. Other community based strategies (specify):________________________________	1 	2 	M

1c. SERVICES

The next questions ask about the services that your Healthy Start project provides.

all

1.10. What percentage of your participants receive the following services? Your best estimate is fine. (NHSPS 1.1 modified)

Include services offered directly to participants by Healthy Start staff and services offered to participants through contracts with other organizations in the community.

Select one per row.

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. Case management services (including service coordination, referral follow-up, etc.)	1 	2 	3 	4 	5 	6 	M
b. Developmental screenings for children	1 	2 	3 	4 	5 	6 	M
c. Enabling services (transportation, child care, etc.)	1 	2 	3 	4 	5 	6 	M
d. Health education and promotion	1 	2 	3 	4 	5 	6 	M
e. Health insurance outreach and enrollment services	1 	2 	3 	4 	5 	6 	M
f. Linkage to medical home providers	1 	2 	3 	4 	5 	6 	M
g. Linkage to mental and behavioral health services	1 	2 	3 	4 	5 	6 	M
h. Parenting education services	1 	2 	3 	4 	5 	6 	M
i. Patient navigation	1 	2 	3 	4 	5 	6 	M
j. Reproductive life planning services	1 	2 	3 	4 	5 	6 	M
k. Services that address toxic stress and adverse childhood experiences (ACE)	1 	2 	3 	4 	5 	6 	M
l. Other (specify): ________________________________	1 	2 	3 	4 	5 	6 	M

All

1.11. What percentage of your project participants receive the following types of referrals through Healthy Start? Your best estimate is fine. (NHSPS 1.14 modified)

Select one per row.

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. Breastfeeding support	1 	2 	3 	4 	5 	6 	M
b. Child care	1 	2 	3 	4 	5 	6 	M
c. Intimate partner violence	1 	2 	3 	4 	5 	6 	M
d. Education services	1 	2 	3 	4 	5 	6 	M
e. Employment services	1 	2 	3 	4 	5 	6 	M
f. Housing/heating	1 	2 	3 	4 	5 	6 	M
g. Immigration	1 	2 	3 	4 	5 	6 	M
h. Medical home/care—infant	1 	2 	3 	4 	5 	6 	M
i. Medical home/care—woman	1 	2 	3 	4 	5 	6 	M
j. Transportation	1 	2 	3 	4 	5 	6 	M
k. WIC/food assistance	1 	2 	3 	4 	5 	6 	M
l. Other type of referral not listed above (specify): ________________________________	1 	2 	3 	4 	5 	6 	M

1d. STAFFING

The next questions are about how your Healthy Start project is staffed.

all

1.12. How many staff members are employed directly by your Healthy Start project? Your best estimate is fine.

Please include all staff whose positions are fully or partially funded by your Healthy Start project, counting contractor staff.

	Number of Staff Employed Directly by Healthy Start	Number of Contract Staff
a. Full-time (paid for 35+ hours per week)
b. Part-time (paid for less than 35 hours per week)

all

1.13. How many of your staff are former Healthy Start participants? (NHSPS 1.4)

Number of staff

(RANGE 0–1000)

 NO RESPONSE M

1e. RETENTION

The next set of questions asks about your Healthy Start project’s experience retaining participants.

all

1.14. To what extent has retention of Healthy Start participants been a problem for your Healthy Start project? (NHSPS 1.10 modified)

Select one only.

 Not a problem 1 SKIP TO 1.16

 Somewhat of a problem 2

 A big problem 3

NO RESPONSE M SKIP TO 1.16

1.14 = 2, 3

1.15. What are the barriers and challenges to retaining participants in your Healthy Start project?

Select all that apply

 Difficulty contacting participants/transience 1 SKIP TO 2.1

 Lack of staff for follow-up 2 SKIP TO 2.1

 Participant lack of time/competing priorities 3 SKIP TO 2.1

 Participant lack of interest 4 SKIP TO 2.1

 Participant lack of transportation 5 SKIP TO 2.1

 Participant lack of child care 6 SKIP TO 2.1

 Participant lack of family support 7 SKIP TO 2.1

 Lack of community support 8 SKIP TO 2.1

 Other challenges not listed above 99 SKIP TO 2.1

Specify (STRING 1000)

NO RESPONSE M SKIP TO 2.1

1.14 = 1

1.16. What factors have facilitated retention of participants in your Healthy Start project? (NHSPS 1.3 mod)

Select all that apply

 Contact and follow-up with participants’ homes at least monthly 1

 Provide incentives (such as books, baby supplies, coupons, prizes,
and gifts) 2

 Provide of child care for participants 3

 Provide food for participants 4

 Provide transportation for participants 5

 Involve males and family members in Healthy Start 6

 Engage community in Healthy Start 7

 Other retention strategy not listed above 99

Specify (STRING 1000)

NO RESPONSE M

SECTION 2. IMPROVE WOMEN’S HEALTH

The questions in Section 2 ask about what your Healthy Start project is doing to improve women’s health.

2a. COMPREHENSIVE ASSESSMENT

The next series of questions asks about the comprehensive needs/risk assessment conducted by your Healthy Start project.

all

2.1. Does your Healthy Start project conduct a comprehensive needs/risk assessment for participants?

For the purposes of this section, a comprehensive needs/risk assessment is defined as an assessment of a participant’s risk factors and protective factors that help your project identify the specific needs of the participant and/or assign the participant to a certain risk level.

Select one only.

 Yes 1

 No 0 SKIP TO 2.6

NO RESPONSE M SKIP TO 2.6

2.1 = 1

2.2 During [GRANT YEAR], what percentage of participating women received a comprehensive needs/risk assessment?

Select one only.

 0% 1

 1 - 24% 2

 25 - 49% 3

 50 – 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

2.1 = 1

2.3a. On average, how frequently does your Healthy Start project conduct a comprehensive needs/risk assessment for preconceptional/interconceptional participants?

Select one only.

 Once at enrollment only 1

 Once per year 2

 Twice per year 3

 Every three months 4

 Every two months 5

 Monthly 6

 Other (Specify) 99

Specify (STRING 1000)

NO RESPONSE M

2.1 = 1

2.3b. On average, how frequently does your Healthy Start project conduct a comprehensive needs/risk assessment for pregnant participants?

Select one only.

 Once at enrollment only 1

 Once per year 2

 Twice per year 3

 Every three months 4

 Every two months 5

 Monthly 6

 Other (Specify) 99

Specify (STRING 1000)

NO RESPONSE M

2.1 = 1

2.4. For each risk factor listed below, indicate which participants are screened for the risk factor as part of a comprehensive needs/risk assessment.

Select all that apply per row.

	Preconceptional/ Interconceptional Participants	Pregnant Participants	Project Does Not Screen for This Risk Factor Regardless of Life Stage	No Response
a. Alcohol and other drugs	1 	2 	3 	M
b. Depression	1 	2 	3 	M
c. Diabetes	1 	2 	3 	M
d. Domestic/intimate partner violence	1 	2 	3 	M
e. Healthy weight/BMI	1 	2 	3 	M
f. HIV	1 	2 	3 	M
g. Hypertension	1 	2 	3 	M
h. Nutrition/physical activity	1 	2 	3 	M
i. Sickle cell disease	1 	2 	3 	M
j. Smoking/exposure to secondhand smoke	1 	2 	3 	M
k. STDs other than HIV	1 	2 	3 	M
l. Other medical risks (specify): ___________________	1 	2 	3 	M
m. Other mental health risks (specify): ___________________	1 	2 	3 	M

any 2.4a through 2.4m = 1 OR 2

2.5. Does your Healthy Start project provide services and/or make referrals for women screening positive for the risk factors listed below?

Select all that apply per row.

[ONLY DISPLAY IF 2.4=1 OR 2]	Provide service	Make referral	Project does not provide service or referral	No Response
a. Alcohol and other drugs	1 	2 	3 	M
b. Depression	1 	2 	3 	M
c. Diabetes	1 	2 	3 	M
d. Domestic/intimate partner violence	1 	2 	3 	M
e. Overweight/Obesity	1 	2 	3 	M
f. HIV	1 	2 	3 	M
g. Hypertension	1 	2 	3 	M
h. Poor nutrition/physical inactivity	1 	2 	3 	M
i. Sickle cell disease	1 	2 	3 	M
j. Smoking/exposure to secondhand smoke	1 	2 	3 	M
k. STDs other than HIV	1 	2 	3 	M
l. Other medical risks	1 	2 	3 	M
m. Other mental health risks	1 	2 	3 	M

2b. CASE MANAGEMENT

The next series of questions is about how your Healthy Start project organizes and delivers case management services.

ALL

2.6. Which case management model(s)/approach(es) does your Healthy Start project use?

Select one per row.

	Yes	No	No Response
a. Assertive community treatment/intensive case management, (team-based approaches)	1 	2 	M
b. The brokerage/generalist mode	1 	2 	M
c. Clinical case management	1 	2 	M
d. Comprehensive case management	1 	2 	M
e. Home visiting	1 	2 	M
f. Strengths-based case management	1 	2 	M
g. Supportive case management	1 	2 	M
h. Other (specify):________________________________	1 	2 	M

ALL

2.7. For each type of participant listed below, what factors does your Healthy Start project consider when assigning case managers? (NHSPS 4.3 modified)

Select all that apply per row.

FACTORS INFLUENCING CASE MANAGER ASSIGNMENT

Caseload or Staff Availability

Geo-graphic Location

Participant Culture and Language

Participant Health Status or Risk Factors

No Particular Assignment Criteria Are Used

Other (Specify)

No Response

a. Preconcep-tional/inter-conceptional women

1 

2 

3 

4 

5 

6 

M

b. Pregnant women

1 

2 

3 

4 

5 

6 

M

c. Infants/ toddlers

1 

2 

3 

4 

5 

6 

M

ALL

2.8. For each type of participant listed below, does your Healthy Start project assign a single case manager, a team of case managers, or does it depend on participant risk level?

Select all that apply per row.

	CASE MANAGER ASSIGNED
	Single Case Manager	Team of Case Managers	Depends on Participant Risk Level	No Response
a. Preconceptional/interconceptional women	1 	2 	3 	M
b. Pregnant women	1 	2 	3 	M
c. Infants/toddlers	1 	2 	3 	M

ALL

2.9. During [GRANT YEAR], what was the average caseload for Healthy Start case managers? Your best estimate is fine. (NHSPS 4.13 modified)

To calculate average caseload, divide the total number of participants receiving case management services by the total number of case management employees or contracted staff.

Enter 0 if your Healthy Start project does not provide case management services to a certain group of participants.

PROGRAMMER: INSERT COMMA FIELD MASK

	Average caseload	Project does not provide case management to this type of participant	No Response
a. Preconception/ interconceptional women		2 	M
b. Pregnant/prenatal women		2 	M
c. Infants and toddlers (0–23 months)		2 	M

ALL

2.10. Does your Healthy Start project develop written service plans for participants? (NHSPS 4.4)

 Yes 1

 No 0 SKIP TO 2.12

NO RESPONSE M SKIP TO 2.12

2.10 = 1

2.11. How are participants involved in the development of the service plan? (NHSPS 4.5)

Select all that apply

 Participants are not involved in the development of the service plan 1

 Participants attend meeting(s) to develop the service plan 2

 Participants sign/ initial the service plan 3

 Participants receive a written copy of the service plan 4

 Other type of involvement (specify) 99

Specify (STRING 1000)

NO RESPONSE M

ALL

2.12. What types of case management interactions/appointments does your Healthy Start project have with participants? (NHSPS 4.9 modified)

Select one per row.

	Yes	No	No Response
a. Face to face at Healthy Start site	1 	2 	M
b. Home visit	1 	2 	M
c. Face to face at location other than Healthy Start or home	1 	2 	M
d. Telephone call	1 	2 	M
e. Email	1 	2 	M
f. Text messaging	1 	2 	M
g. Skype	1 	2 	M
h. Mail	1 	2 	M
i. Other (specify):________________________________	1 	2 	M

ALL

2.13. Through which period do women in your Healthy Start project typically receive case management services? (NHSPS 4.17 modified)

Select one only.

 Through pregnancy (not postpartum) 1

 Post-delivery to 6 months postpartum 2

 6–11 months postpartum 3

 12–17 months postpartum 4

 18–23 months postpartum 5

 2 years postpartum 6

 25 months or more postpartum 7

 Case management services are offered to all women 8

NO RESPONSE M

ALL

2.14. Through what age are case management services typically offered to infants and toddlers in your Healthy Start project? (NHSPS 4.18 modified)

Select one only.

 Less than 6 months of age 1

 6–11 months of age 2

 12–17 months of age 3

 18–23 months of age 4

 2 years of age 5

 3–5 years of age 6

 Greater than 5 years of age 7

 Other (Specify) 99

Specify (STRING 1000)

NO RESPONSE M

ALL

2.15. How frequently are women reassessed for their eligibility for case management services?

Select one only.

 Every 12 months 1

 Every 6 months 2

 Every 3 months 3

 Every 2 months 4

 Monthly 5

 Other (Specify) 99

Specify (STRING 1000)

NO RESPONSE M

ALL

2.16. How are participants followed by your Healthy Start project when they are referred to another provider (such as a primary health care provider, mental health service provider, or social service provider in the community)? (NHSPS 4.57)

Select one per row.

	Yes	No	No Response
a Chart review/medical record review	1 	2 	M
b. Case conference/team meeting	1 	2 	M
c. Regular communication between Healthy Start and the participant	1 	2 	M
d. Regular communication between the referred agency and Healthy Start	1 	2 	M
e. Other means of being followed, not listed above: _____________________	1 	2 	M

ALL

2.17. How do Healthy Start staff follow up with participants after making referrals? (NHSPS 4.61 modified)

Select one per row.

	Yes	No	No Response
a. Face to face at Healthy Start site	1 	2 	M
b. Home visit	1 	2 	M
c. Face to face at location other than Healthy Start or home	1 	2 	M
d. Telephone call	1 	2 	M
e. Email	1 	2 	M
f. Text messaging	1 	2 	M
g. Skype	1 	2 	M
h. Mail	1 	2 	M
i. Other (specify):________________________________	1 	2 	M

2c. HEALTH INSURANCE ENROLLMENT SERVICES

all

2.18. During [GRANT YEAR], what percentage of your Healthy Start project participants were uninsured at intake? Your best estimate is fine. (NHSPS 4.82 modified)

Uninsured participants do not have any coverage to help pay for medical services or prescriptions. Include both participating women and children.

Select one only.

 0% 1

 1 - 24% 2

 25 - 49% 3

 50 – 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

all

2.19. Does your Healthy Start project use a protocol to identify whether women have health insurance coverage?

 Yes 1

 No 0 SKIP TO 2.21

NO RESPONSE M SKIP TO 2.21

2.19 = 1

2.20. During which of the following types of interactions with participants does your Healthy Start project use a protocol to identify whether participants have health insurance coverage?

Select one per row.

	Yes	No	No Response
a. During community outreach/recruitment	1 	2 	M
b. During comprehensive needs/risk assessment	1 	2 	M
c. During regular case management interactions	1 	2 	M
d. During home visits	1 	2 	M
e. Other type of interaction not listed above (specify): ________________________________	1 	2 	M

ALL

2.21. Did your Healthy Start project apply to be a CAC organization through CMS?

Certified application counselor (CAC) organizations are approved by the Centers for Medicare & Medicaid Services (CMS) to help people understand, apply for, and enroll in health coverage through the Health Insurance Marketplace.

 Yes 1

 No 0 SKIP TO 2.23

NO RESPONSE M SKIP TO 2.23

2.21 = 1

2.22. Was your Healthy Start project’s certified application counselor (CAC) application approved?

 Yes 1

 No 0

NO RESPONSE M

ALL

2.23. IF 2.22 = 1(ORG IS CAC ORG): Even if your organization is a certified application counselor (CAC) organization, does your Healthy Start project have a formal partnership with any certified application counselor (CAC) organizations in the community?

IF 2.21 = 0 or 2.22 = 0 (ORG IS NOT CAC ORG): Does your Healthy Start project have a formal partnership with any certified application counselor (CAC) organizations in the community?

A formal partnership can be defined as a written agreement (usually involving a subcontract or memorandum of understanding [MOU]) with an organization to offer services to Healthy Start participants.

A subcontract is a legally binding document with an organization stating that the organization will provide services for Healthy Start.

An MOU is a written agreement between entities that formalizes a relationship, but it is not legally binding like a contract.

 Yes 1

 No 0

NO RESPONSE M

ALL

2.24. [IF 2.22 = 1: Even if your organization is a certified application counselor (CAC) organization, does]/ [If 2.21 = 0 or 2.22 = 0: Does] your Healthy Start project have an informal partnership with any certified application counselor (CAC) organizations in the community?

An informal partnership can be defined as an agreement that is not written.

 Yes 1

 No 0

NO RESPONSE M

ALL

2.25. Is your Healthy Start project a marketplace navigator organization (federally facilitated marketplace) or have non-Navigator assistance personnel (state-based marketplace or state partnership marketplace) on staff?

Organizations with Marketplace Navigators or non-Navigator assistance personnel receive grant funding to train and hire staff that help people understand, apply for, and enroll in health coverage through the Health Insurance Marketplace.

 Yes 1

 No 0

NO RESPONSE M

ALL

2.26. Does your Healthy Start project have a formal partnership with a Marketplace Navigator organization (federally facilitated marketplace) or non-Navigator assistance personnel (state-based marketplace or state partnership marketplace)?

 Yes 1

 No 0

NO RESPONSE M

ALL

2.27. Does your Healthy Start project have an informal agreement with a Marketplace Navigator organization (federally facilitated marketplace) or non-Navigator assistance personnel (state-based marketplace or state partnership marketplace)?

 Yes 1

 No 0

NO RESPONSE M

ALL

2.28. What types of health insurance enrollment services does your Healthy Start project offer on site?

Do not include services for which your project refers participants to other organization or agencies.

Select all that apply

 Processes insurance applications for participants on site 1

 Identifies if a participant qualifies for insurance affordability programs
(like Medicaid, CHIP, and premium tax credits) 2

 Assists participants and answers basic questions about applications 3

 Provides translation/interpreter services for participants to assist
with application process 4

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

2d. SUPPORT FOR PREVENTION

The next questions ask how your Healthy Start tracks preventative health services and health outcomes.

All

2.29. Does your Healthy Start project help participants develop a reproductive life plan?

A reproductive life plan is a tool to assist women in determining if or when they plan to have children and in identifying family planning methods to help them fulfill their plan.

 Yes 1

 No 0 SKIP TO 2.31

NO RESPONSE M SKIP TO 2.31

2.29 = 1

2.30. During [GRANT YEAR], what percentage of participants developed a reproductive life plans? Please report by preconceptional/interconceptional and pregnant participants. Your best estimate is fine.

Select one per row

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. Preconceptional/ interconceptional participants	1 	2 	3 	4 	5 	6 	M
b. Pregnant participants	1 	2 	3 	4 	5 	6 	M

All

2.31. Does your Healthy Start project track the following health behaviors and outcomes? Does your project track . . .

Select one per row.

	Yes	No	No Response
a. Trimester of prenatal care	1 	0 	M
b. Receipt of flu shots among pregnant women	1 	0 	M
c. Weight gain during pregnancy	1 	0 	M
d. Overweight, obesity, and underweight among women	1 	0 	M
e. Receipt of well-woman visits	1 	0 	M
f. Women with a primary health care provider or a usual source of care	1 	0 	M
g. Children with a primary health care provider or a usual source of care	1 	0 	M
h. Tobacco use among women	1 	0 	M
i. Alcohol and substance use among women	1 	0 	M
j. Intimate partner/domestic violence	1 	0 	M
k. HIV/AIDS status	1 	0 	M
l. Chlamydia among women	1 	0 	M
m. Other sexually transmitted infections among women	1 	0 	M
n. Postpartum weight loss	1 	0 	M
o. Breastfeeding	1 	0 	M
p. Receipt of well-child visits	1 	0 	M
q. Receipt of immunizations	1 	0 	M
r. Child abuse/neglect	1 	0 	M

2.31F AND/OR 2.31G = 1

2.32. During [GRANT YEAR], what percentage of participants in your Healthy Start project had a primary health care provider (PCP) or usual source of care?

Please report by preconceptional/interconceptional women, pregnant women, and children ages two and younger. Your best estimate is fine. (NHSPS 4.48 modified)

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. Preconceptional/ interconceptional participants	1 	2 	3 	4 	5 	6 	M
b. Pregnant participants	1 	2 	3 	4 	5 	6 	M
c. Children ages ≤ 2	1 	2 	3 	4 	5 	6 	M

All

2.33. Which of the following does your Healthy Start project track regarding referrals to primary health care providers? (NHSPS 4.47)

Select one per row.

	Yes	No	No Response
a. Providers available for referral of clients	1 	2 	M
b. Referrals made	1 	2 	M
c. Referrals completed	1 	2 	M
d. Services provided	1 	2 	M
e. Diagnoses	1 	2 	M
f. Clinical Outcomes	1 	2 	M
g. Other (specify): ________________________________	1 	2 	M

2.31H = 1

2.34. During [GRANT YEAR], what percentage of women participating in your Healthy Start project . . .

Your best estimate is fine. (NHSPS 6.12 modified)

Select one per row.

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. …Used tobacco in any form	1 	2 	3 	4 	5 	6 	M
b. …Were smokers	1 	2 	3 	4 	5 	6 	M
c. …Quit using tobacco during their participation in the project among smokers	1 	2 	3 	4 	5 	6 	M
d. …Relapsed after quitting smoking for three or more months among those that quit smoking	1 	2 	3 	4 	5 	6 	M

2.31I = 1

2.35. During [GRANT YEAR], what percentage of women participating in your Healthy Start project . . .

Your best estimate is fine. (NHSPS 6.13 modified)

Select one per row.

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. …Used alcohol or drugs or other substances	1 	2 	3 	4 	5 	6 	M
b. …Quit abusing alcohol or using drugs during their participation in the project among those that used alcohol	1 	2 	3 	4 	5 	6 	M
c. …Relapsed after discontinuing drug or alcohol use for three or more months among those that quite abusing alcohol	1 	2 	3 	4 	5 	6 	M

2.31O = 1

2.36. During [GRANT YEAR], approximately what percentage of participants with a live birth 6 months before the end of the year breastfed their infant . . .

Your best estimate is fine. (NHSPS 6.21 modified)

Breastfeeding is feeding an infant with milk from the mother, which includes milk pumped from the breast and fed to the baby in a bottle.

Select one per row.

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. …At hospital discharge?	1 	2 	3 	4 	5 	6 	M
b. …At 6 months of age (partially or exclusively)?	1 	2 	3 	4 	5 	6 	M
c. …At 6 months of age exclusively?	1 	2 	3 	4 	5 	6 	M

2.31K = 1 or 2.31l = 1 or 2.31m = 1 (see fills below)

2.37. During [GRANT YEAR], what percentage of women participating in your Healthy Start project . . .

Your best estimate is fine. (NHSPS 6.12 modified)

Select one per row.

	0%	1 – 24%	25 – 49%	50 – 74%	74 – 99%	100%	No Response
a. [IF 2.31K = 1] …Tested positive for HIV/ AIDs?	1 	2 	3 	4 	5 	6 	M
b. [IF 2.31L = 1] …Tested positive for chlamydia?	1 	2 	3 	4 	5 	6 	M
c. [IF 2.31M = 1] …Tested positive for any sexually transmitted infection?	1 	2 	3 	4 	5 	6 	M

SECTION 3. PROMOTE QUALITY SERVICES

The questions in Section 3 ask about the following Healthy Start project activities: service coordination and linkage to a medical home, other standardized curricula and home visiting, culturally competent services, health promotion, and tobacco cessation.

3a. SERVICE COORDINATION AND MEDICAL HOME

The next questions ask about how your Healthy Start project coordinates services with health care providers and links participants to a medical home.

All

3.1. Does your Healthy Start project use protocols to: (NHSPS 4.83)

Select one per row.

	Yes	No	No Response
a. Assess whether participants have a primary health care provider	1 	2 	M
b. Assess whether participants’ children have a primary health care provider	1 	2 	M

all

3.2. At what stage does your Healthy Start project ensure linkage to a primary health care provider/usual source of care? (NHSPS 4.67 modified)

A primary health care provider/usual source of care is a doctor, nurse, or health care setting that people regularly go to get help preventing, diagnosing, and treating illness.

Select one only.

 Before pregnancy 1

 During pregnancy 2

 Postpartum 3

 Linkage to a primary health care provider is established immediately
upon entry into the project for all women, regardless of perinatal stage 4

 Our Healthy Start project does not establish linkages to a primary
health care provider for participants 5

NO RESPONSE M

all

3.3. Are primary health care services available to women on site?

On-site primary health care services are those that operate in the same physical location as Healthy Start services.

 Yes 1

 No 0

NO RESPONSE M

all

3.4. Are primary health care services available to infants on site?

 Yes 1

 No 0

NO RESPONSE M

all

3.5. Does your Healthy Start project have formal partnerships with primary health care providers? (NHSPS 4.69)

A formal partnership can be defined as a written agreement (usually involving a subcontract or memorandum of understanding [MOU]) with providers to provide care to Healthy Start participants.

A subcontract is a legally binding document with an organization that states that the organization will provide services for Healthy Start.

An MOU is a written agreement between entities that formalizes a relationship, but it is not legally binding as a contract.

 Yes 1

 No 0 SKIP TO 3.10

NO RESPONSE M SKIP TO 3.10

The next series of questions asks about primary health care providers with which your Healthy Start project has formal partnerships.

3.5 = 1

3.6. During [GRANT YEAR], with how many primary health care providers did your Healthy Start project have an MOU or contract? Your best estimate is fine. (NHSPS 4.70, 4.77 modified)

Number of Primary Health Care Providers with MOU or contract

(RANGE 0–1000)

NO RESPONSE M

3.5 = 1

3.7. In what setting(s) do your project’s formal partner primary health care providers provide health care to women? (NHSPS 4.74 modified)

Select all that apply

 Clinic or health center 1

 Doctor’s office or HMO 2

 Hospital emergency room 3

 Hospital outpatient department 4

 Other 99

Specify (STRING 1000)

NO RESPONSE M

3.5 = 1

3.8. In what setting(s) do your project’s formal partner primary health care providers provide health care to infants? (NHSPS 4.75)

Select all that apply

 Clinic or health center 1

 Doctor’s office or HMO 2

 Hospital emergency room 3

 Hospital outpatient department 4

 Other 99

Specify (STRING 1000)

NO RESPONSE M

3.5 = 1

3.9. During [GRANT YEAR], what percentage of your project’s formal partner primary health care providers were considered patient-centered medical home providers? Your best estimate is fine. (NHSPS 4.79 modified)

A patient-centered medical home (1) provides patients with a regular source of care, (2) is not difficult to contact, (3) provides medical care or advice after hours, and (4) is well organized and generally on time with appointments.

Select one only.

 0% 1

 1–24% 2

 25 - 49% 3

 50 - 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

All

3.10. Does your Healthy Start project make referrals to primary health care providers other than those with whom your project formally partners?

Include providers with whom your project has informal agreements and providers to whom your project refers women but with whom your project does not have a formal written agreement.

 Yes 1

 No 0 SKIP TO 3.14

NO RESPONSE M SKIP TO 3.14

The next series of questions is about primary care providers to whom your project refers women but with whom your project does not have a formal, written agreement.

3.10 = 1

3.11. During [GRANT YEAR], with how many primary health care providers did your Healthy Start project have informal partnerships? Your best estimate is fine. (NHSPS 4.76)

Number of primary health care providers with informal partnership

(RANGE 0–1000)

NO RESPONSE M

3.10 = 1

3.12a. In what setting(s) do your informal partner primary health care providers provide health care to women? (NHSPS 4.52)

Select all that apply

 Clinic or health center 1

 Doctor’s office or HMO 2

 Hospital emergency room 3

 Hospital outpatient department 4

 Other 99

Specify (STRING 1000)

NO RESPONSE M

3.10 = 1

3.12b. In what setting(s) do your informal partner primary health care providers provide health care to infants? (NHSPS 4.53 modified)

Select all that apply

 Clinic or health center 1

 Doctor’s office or HMO 2

 Hospital emergency room 3

 Hospital outpatient department 4

 Other 99

Specify (STRING 1000)

NO RESPONSE M

3.10 = 1

3.13. By definition, a medical home (1) provides patients with a regular source of care, (2) is not difficult to contact, (3) provides medical care or advice after hours, and (4) is well organized and generally on time with appointments.

During [GRANT YEAR], what percentage of your informal partner primary health care providers were considered patient-centered medical home providers? Your best estimate is fine. (NHSPS 4.54 modified)

Select one only.

 0% 1

 1–24% 2

 25 - 49% 3

 50 - 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

ALL

3.14. Which of the following services are offered by formal and informal partner primary care providers to which your Healthy Start project refers women? (NHSPS 4.55 modified)

Select one per row.

	Yes	No	No Response
a. Chronic disease management	1 	2 	M
b. Dental care	1 	2 	M
c. Emergency services	1 	2 	M
d. HIV/STI testing	1 	2 	M
e. Routine primary health care	1 	2 	M
f. Medical specialists referrals	1 	2 	M
g. Mental/behavioral health care	1 	2 	M
h. OB/GYN services	1 	2 	M
k. Weight management	1 	2 	M
i. Referrals to other health services:___________________	1 	2 	M
j. Referrals to social services (WIC, housing):___________	1 	2 	M

ALL

3.15. Which of the following services are offered by formal and informal partner primary care providers to which your Healthy Start project refers children? (NHSPS 4.56)

Select one per row.

	Yes	No	No Response
a. Dental care	1 	2 	M
b. Emergency services	1 	2 	M
c. Immunizations	1 	2 	M
d. Medical specialist referrals	1 	2 	M
e. Mental/behavioral health care	1 	2 	M
f. Routine pediatric care	1 	2 	M
g. Referrals to other health services: ___________________	1 	2 	M
h. Referrals to social services (such as, WIC): ___________________	1 	2 	M

ALL

3.16. What percentage of the primary health care providers to whom your Healthy Start project refers women use electronic medical records (EMRs) or electronic health records (EHRs)? Your best estimate is fine. (NHSPS 4.80 modified)

Select one only.

 0% 1

 1–24% 2

 25 - 49% 3

 50 - 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

all

3.17. What services or assistance does your Healthy Start project offer to link participants with a primary health care provider/usual source of care? (NHSPS 4.68)

Select all that apply

 Healthy Start staff make appointments for participants 1

 Healthy Start staff may accompany participant to first few appointments 2

 Free health services offered on site by provider at Healthy Start location 3

 Translation/interpreter services are paid for participants 4

 Transportation services, stipends, or vouchers offered to participants 5

 Other services or assistance not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

3b. OTHER STANDARDIZED CURRICULA/HOME VISITING

The next questions ask about other curricula your Healthy Start project uses, including home visiting curricula.

all

3.18. Which of the following models does your Healthy Start project use as part of or in addition to your project’s case management model?

Select one per row.

	Yes	No	No Response
a. Bright Futures	1 	2 	M
b. Centering Pregnancy	1 	2 	M
c. A home visiting model (eg. HFA, PAT)	1 	2 	M
d. Other (specify): ________________________________	1 	2 	M

all

3.19. Does your Healthy Start project offer home visiting services to participants?

 Yes 1

 No 0 SKIP TO 3.29

NO RESPONSE M SKIP TO 3.29

3.19 = 1

3.20. Which models/ curricula does your Healthy Start project use for your home visiting program? (NHSPS 4.24 modified)

Select one per row.

	Yes	No	No Response
a. Child FIRST	1 	2 	M
b. Early Head Start (EHS)–Home Visiting	1 	2 	M
c. Early Intervention Program for Adolescent Mothers	1 	2 	M
d. Early Start (New Zealand)	1 	2 	M
e. Family Check-Up	1 	2 	M
f. Healthy Families America (HFA)	1 	2 	M
g. Healthy Steps	1 	2 	M
h. The Home Instruction Program for Preschool Youngsters (HIPPY)	1 	2 	M
i. Maternal Early Childhood Sustained Home Visiting Program (MESCH)	1 	2 	M
j. Nurse Family Partnership (NFP)	1 	2 	M
k. Oklahoma Community-Based Family Resource and Support Program	1 	2 	M
l. Parents as Teachers (PAT)	1 	2 	M
m. Play and Learning Strategies (PALS) Infant	1 	2 	M
n. SafeCare Augmented	1 	2 	M
o. Other (specify): ________________________________	1 	2 	M
p. We do not use a specific home visiting model	1 	2 	M

3.19 = 1

3.21. During [GRANT YEAR], how many staff conducted home visits? Your best estimate is fine. (NHSPS 4.28 modified)

Please include all staff whose positions are fully or partially funded by your Healthy Start project, counting contractor staff.

Staff

(RANGE 0–1000)

NO RESPONSE M SKIP TO 3.23

3.21 Populated

3.22. Are home visits conducted by Healthy Start staff, contracted staff, or both? (NHSPS 4.29)

Select one only.

 Healthy Start staff only 1

 Contracted staff only 2

 Both Healthy Start and contracted staff 3

NO RESPONSE M

3.19 = 1

3.23. Who is served through home visits conducted by your Healthy Start project? (NHSPS 4.35 modified)

Select all that apply

 Preconceptional/interconceptional women 1

 Pregnant women 2

 Infant and toddlers (0–24 months) 3

 Families—women, children, and partners 4

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

3.19 = 1

3.25. When does your Healthy Start project initiate home visits with women? (NHSPS 4.37 modified)

Select one only.

 During preconceptional/interconceptional period 1

 During pregnancy/prenatal 2

 During the postpartum period 3

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

3.19 = 1

3.26. How often are home visits conducted for . . . (NHSPS 4.40 modified)

Select all that apply per row.

	FREQUENCY OF HOME VISITS
Types of Participants	Weekly	Every Other Week	Every Month	Every 2 Months	Every 3 Months	Every 6 Months	Every 12 Months	Other (Specify Frequency in Box)	No Response
a. Preconceptional/ interconceptional women?	1 	2 	3 	4 	5 	6	7		M
b. Pregnant women?	1 	2 	3 	4 	5 	6 	7 		M
c. Infants and toddlers (0–24 months)?	1 	2 	3 	4 	5 	6 	6 		M

3.19 = 1

3.27. On average, what is the duration of a scheduled home visit? (NHSPS 4.39 modified)

Select one only.

 Less than 30 minutes 1

 At least 30 minutes but less than an hour 2

 At least 1 hour but less than 2 hours 3

 At least 2 hours but less than 3 hours 4

 3 hours or more 5

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

3.19 = 1

3.28. Which of the following services are provided during home visits? (NHSPS 4.41)

Select one per row.

	Yes	No	No Response
a. Child development assessment	1 	2 	M
b. Depression screening	1 	2 	M
c. Enabling services (e.g., job training/placement, educational support/tutoring)	1 	2 	M
d. Group meetings or group education sessions (held at a participant’s home)	1 	2 	M
e. Health education (e.g., nutrition, substance use)	1 	2 	M
f. Health services (e.g., well-baby checkups)	1 	2 	M
g. Individual counseling	1 	2 	M
h. Parenting education	1 	2 	M
i. Referrals to enabling services	1 	2 	M
j. Referrals to health services	1 	2 	M
k. Reproductive health, contraception education	1 	2 	M
l. Needs/risk assessment	1 	2 	M
m. Other services (specify): ________________________________	1 	2 	M

3c. CULTURAL AND LINGUISTIC COMPETENCE

The next questions ask about how your Healthy Start project supports service provision that is culturally and linguistically appropriate.

All

3.29. What languages are spoken by participants? If additional languages are spoken by participants, specify those languages in the spaces below. (NHSPS 2.15 modified)

Select all that apply

 English 1

 Spanish 2

 French 3

 Portuguese 4

 Cambodian (Khmer) 5

 Chinese 6

 Haitian Creole 7

 Japanese 8

 Korean 9

 Vietnamese 10

 Arabic 11

 Other (specify) 99

Specify Language #1 (STRING 50)

Specify Language #2 (STRING 50)

Specify Language #3 (STRING 50)

NO RESPONSE M

all

3.30. How does your Healthy Start project promote the cultural competence of your project’s employees and contractor staff? (NHSPS 2.14)

Select all that apply

 Hire staff who represent racial/ethnic makeup of our target population 1

 Require contractors to employ staff reflective of target population 2

 Provide cultural competence/sensitivity training 3

 Our Healthy Start project does not implement particular strategies to
promote cultural competence of our employees and contractor staff 4

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

3.31. What challenges does your Healthy Start project encounter in promoting the cultural and linguistic competence of your Healthy Start staff and contracted providers? (NHSPS 2.17)

Select all that apply

 There are not enough qualified staff in the community 1

 We do not have adequate funding to hire culturally and linguistically

competent staff 2

 We don’t have staff to cover all cultural groups and languages 3

 Other challenge (specify): 99

Specify (STRING 1000)

NO RESPONSE M

all

3.32. What efforts are made by Healthy Start staff to assess new participants’ cultures and languages during enrollment? (NHSPS 2.18)

Select all that apply

 Ask about beliefs about pregnancy and health 1

 Ask about customs/spiritual beliefs 2

 Ask country of origin 3

 Listen to dialects 4

 Our Healthy Start project does not perform an assessment of participant’s
culture 5

 Other challenge (specify): 99

Specify (STRING 1000)

NO RESPONSE M

3d. FOCUS ON PREVENTION AND HEALTH PROMOTION

The next questions ask about how your Healthy Start project delivers health education services to participants and community members.

ALL

3.33. What mass media strategies does your Healthy Start project use to provide health education in the community? (NHSPS 1.6b)

Select one per row.

	Yes	No	No Response
a. Brochures/fliers/mailings	1 	2 	M
b. Internet advertising/social media	1 	2 	M
c. Newspaper/print advertising (ads, articles)	1 	2 	M
d. Posters/billboards	1 	2 	M
e. Radio (ads, PSAs, talk shows)	1 	2 	M
f. TV (ads, PSAs, talk shows)	1 	2 	M
g. Other mass media strategies (specify): _________________	1 	2 	M

ALL

3.34. What community-based strategies does your Healthy Start project use to provide health education and health promotion? (NHSPS 1.5b)

Select one per row.

	Yes	No	No Response
a. Conduct classes or make presentations to local community groups	1 	2 	M
b. Conduct one-on-one education/counseling	1 	2 	M
c. Operate hotline(s)	1 	2 	M
d. Conduct presentations to health care providers and other groups serving population	1 	2 	M
e. Provide sessions and information at community events, including health fairs	1 	2 	M
f. Put out messages through media outlets	1 	2 	M
g. Other activity (specify): _________________________________	1 	2 	M

ALL

3.35. What methods does your Healthy Start project use to promote individual health education among participants?

Select all that apply

 Case managers conduct health education during interactions with clients 1

 Home visitors conduct health education with clients during visits 2

 Motivational interviewing 3

 Provide packets of information to all clients upon enrollment 4

 Telephone and computer education applications/modules 5

 Other strategies (specify) 99

Specify (STRING 1000)

NO RESPONSE M

ALL

3.36. Which of the following topics does your Healthy Start project address through classes and counseling? (NHSPS 1.6 modified + 1.42)

Select one per row.

	Yes	No	No Response
a. Child abuse	1 	2 	M
b. Child safety/Injury prevention	1 	2 	M
c. Childhood obesity	1 	2 	M
d. Children’s exercise	1 	2 	M
e. Children’s nutrition	1 	2 	M
f. Education support/GED classes	1 	2 	M
g. Employment/job training	1 	2 	M
h. Fetal alcohol spectrum disorders (FASD)	1 	2 	M
i. Financial planning/budgeting	1 	2 	M
j. Immigration
k. Infant growth and development	1 	2 	M
l. Infant oral health	1 	2 	M
m. Intimate partner violence
n. Reproductive and sexual health	1 	2 	M
o. Sudden unexplained infant death/sudden infant death syndrome	1 	2 	M
p. Other topics (specify): _________________________________	1 	2 	M

Tobacco Cessation Support

all

3.37. Does your Healthy Start project provide education, counseling, referrals, or other services to support smoking/tobacco cessation? (NHSPS 1.21)

 Yes 1

 No 0 SKIP TO 3.42

NO RESPONSE M SKIP TO 3.42

3.37 = 1

3.38. Which of the following tobacco cessation counseling techniques are used by your Healthy Start project and partner agencies? (NHSPS 1.24 modified)

Select one per row.

	Yes	No	No Response
a. The 5 A’s (Ask, Advise, Assess, Assist, and Arrange)	1 	2 	M
b. A modification of the 5 A’s	1 	2 	M
c. Behavior modification	1 	2 	M
d. Linkage to quitlines	1 	2 	M
e. Motivational interviewing	1 	2 	M
f. Peer support/peer Mentoring	1 	2 	M
g. Other tobacco cessation counseling technique (specify): ____________________________	1 	2 	M

3.37 = 1

3.39. Which of the following tobacco use cessation services are offered to participants? (NHSPS 1.28 modified)

Select all that apply

 Group counseling 1

 One-on-one counseling 2

 Tobacco medication options 3

 Tobacco cessation related material 4

 Referrals to community, state-run, or other quitlines 5

 Other tobacco cessation opportunities 99

Specify (STRING 1000)

NO RESPONSE M

3.37 = 1

3.40. Which topics are covered in tobacco cessation counseling conducted by your Healthy Start project and partner agencies? (NHSPS 1.25 modified)

Select all that apply

 Birth outcomes associated with smoking during pregnancy 1

 Community/online smoking cessation networks 2

 Economic benefits of quitting smoking 3

 Health benefits of quitting smoking 4

• Long-term health consequences of smoking 5

 Nicotine replacement options 6

 Outcomes associated with secondhand smoke exposure during infancy
and childhood 7

 Prescription medications to help quit smoking and other tobacco use 8

 Smoking cessation quitlines 9

 Other topic (specify) 99

Specify (STRING 1000)

NO RESPONSE M

3.37 = 1

3.41. Which of the following nicotine replacement and other tobacco cessation medication options are available for participants trying to quit using tobacco? (NHSPS 1.27)

Select all that apply

 Bupropion (Zyban or Wellbutrin SR) 1

 Nicotine gum 2

 Nicotine lozenge 3

• Nicotine nasal spray 4

 Nicotine patch 5

 Varenicline (aka Chantix, Champix) 6

 Other nicotine replacement or tobacco cessation medication (specify) 99

Specify (STRING 1000)

 No nicotine replacement and other tobacco cessation medication
are available 0

NO RESPONSE M

Substance and Alcohol Use

all

3.42. Does your Healthy Start project provide education, counseling, referrals, or other services to support individuals that use alcohol or other drugs?

 Yes 1

 No 0

NO RESPONSE M

all

3.43. What types of services are offered by your Healthy Start project and partner agencies to participants that use alcohol or other drugs?

Select all that apply

 Group counseling 1

 One-on-one counseling 2

 Stopping alcohol and drug use materials 3

 Referrals to other providers 4

 Other counseling 99

Specify (STRING 1000)

NO RESPONSE M

Healthy Weight

all

3.44. What healthy weight–related activities are offered to participants by your Healthy Start project and partner agencies? (NHSPS 1.35 and 1.37 modified)

Select all that apply

 Exercise classes 1

 Literature/reading materials 2

 Nutrition education 3

 One-on-one weight loss support 4

 Weight and pregnancy education 5

 Weight loss support groups 6

 Other healthy weight–related activity (specify) 99

Specify ( STRING 1000)

 Our project does not offer healthy weight activities 0

NO RESPONSE M

all

3.45. Does your Healthy Start project or partner agencies have a nutritionist or someone with a background in nutrition? (NHSPS 1.38 and 1.39)

 Yes 1

 No 0

NO RESPONSE M

Breastfeeding

all

3.46. Does your Healthy Start project conduct education related to breastfeeding? (NHSPS 4.4 modified)

 Yes 1

 No 0 SKIP TO 3.48

NO RESPONSE M SKIP TO 3.48

3.46 = 1

3.47. What specific breastfeeding-related topics are discussed with participants? (NHSPS 4.7)

Select one per row.

	Yes	No	No Response
a. Breastfeeding alternatives for mothers who cannot directly breastfeed (e.g., use of breast pumps)	1 	2 	M
b. Breastfeeding and transitioning back to work	1 	2 	M
c. Common breastfeeding challenges	1 	2 	M
d. Differences between breast milk and formula	1 	2 	M
e. Economic benefits of breastfeeding	1 	2 	M
f. Effects of breastfeeding on fertility	1 	2 	M
g. Infants’ health benefits from breastfeeding	1 	2 	M
h. Mothers’ health benefits from breastfeeding	1 	2 	M
i. Strategies/interventions for overcoming breastfeeding challenges	1 	2 	M
j. Other breastfeeding topic (specify): ________________________	1 	2 	M

ALL

3.48. Does your Healthy Start project have breast pumps available to loan or donate to participants? (NHSPS 4.10 modified)

 Yes 1

 No 0

NO RESPONSE M

ALL

3.49. Does your Healthy Start project have breast shells/breast shields available to donate to participants? (NHSPS 4.10 modified)

 Yes 1

 No 0

NO RESPONSE M

ALL

3.50. Does your Healthy Start project have nursing supplements available to donate to participants? (NHSPS 4.10 modified)

 Yes 1

 No 0

NO RESPONSE M

ALL

3.51. Does your Healthy Start project . . . (NHSPS 4.11 and 4.12 modified)

Select one per row.

	Yes	No	No Response
a. have a certified lactation consultant on site?	1 	2 	M
b. have a doula on site to support breastfeeding?	1 	2 	M
c. have breastfeeding peer counselors?	1 	2 	M
d. provide referrals to individualized lactation consultation?	1 	2 	M

all

3.52. Where does your Healthy Start project refer participants for lactation support? (NHSPS 4.13)

Select all that apply

 WIC 1

 Hospital or clinic 2

 We do not refer participants outside the project for individualized
lactation support 3

 Other referral not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

Intimate Partner Violence

all

3.53. Does your Healthy Start project provide education, counseling, referrals, or other services related to intimate partner violence? (NHSPS 3.31 modified)

Select all that apply

 Yes, group counseling/support groups 1

 Yes, one-on-one counseling 2

 Yes, other service not listed above 99

Specify (STRING 1000)

 No, the project does not have these types of services 0

NO RESPONSE M

all

3.54. Which of the following types of referrals are offered to participants related to intimate partner violence? (NHSPS 3.32 modified)

Select one per row.

	Yes	No	No Response
a. Referrals to crisis hotlines	1 	0 	M
b. Medical referrals for injuries related to intimate partner violence	1 	0 	M
c. Mental health/counseling referrals	1 	0 	M
d. Referrals to shelters/safe havens for women	1 	0 	M
e. Referrals within the criminal justice system	1 	0 	M
f. Referrals to support groups	1 	0 	M
g. Other type of referral not listed above (specify): ____________________________	1 	0 	M

Developmental Screenings for Children

all

3.55. How does your Healthy Start project provide developmental screenings for children?

Select all that apply

 Provided on site 1

 Provided through partner agencies with a formal agreement 2

 Provided through partner agencies with an informal partner agreement 3

 Other referral not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

SECTION 4. STRENGTHEN FAMILY RESILIENCE

The questions in Section 4 ask about what your Healthy Start project is doing to strengthen family resilience.

4a. SUPPORT MENTAL AND BEHAVIORAL HEALTH

The next questions ask about how your Healthy Start project supports mental and behavioral health for participants and their families.

all

4.1. During [GRANT YEAR], what percentage of participating pregnant and preconceptional/interconceptional received a perinatal depression screening from your Healthy Start project or partner agencies? Please report by pregnant and preconception/interconceptional women. Your best estimate is fine. (NHSPS 2.24 modified)

Select one per row.

	0%	1 – 24%	25 – 49%	50 – 74%	75 – 99%	100%	No Response
a. pregnant women receiving a depression screening	1 	2 	3 	4 	5 	6 	M
b. preconceptional/interconceptional women receiving a depression screening	1 	2 	3 	4 	5 	6 	M

IF BOTH 4.1a AND 4.1b = 1 or M (MISSING), SKIP TO 4.3, ELSE CONTINUE.

(4.1a = 2, 3, 4, 5, or 6) or (4.1b = 2, 3, 4, 5 or 6)

4.2. What instrument(s) is used to screen women for perinatal depression?

Select one per row.

	Use	Do Not Use	No Response
a. BDI-FastScreen for Medical Patients (previously known as the Beck Depression Inventory-Primary Care version or BDI-PC)	1 	2 	M
b. Center for Epidemiologic Studies Depression Scale (CES-D)	1 	2 	M
c. Edinburgh Postnatal Depression Scale (EPDS)	1 	2 	M
d. Hamilton Depression Rating Scale (HAM-D)	1 	2 	M
e. Montgomery-Åsberg Depression Rating Scale (MADRS)	1 	2 	M
f. Patient Health Questionnaire-2 (PHQ-2)	1 	2 	M
g. Patient Health Questionnaire-9 (PHQ-9)	1 	2 	M
h. Postpartum Depression Screening Scale (PDSS)	1 	2 	M
i. RAND 3-Question Screen	1 	2 	M
j. Other instrument (specify): _____________________________	1 	2 	M

all

4.3. During [GRANT YEAR] what percentage of participating children received a socio-emotional screening either on site or at a partner site? Your best estimate is fine. (NHSPS 2.24 modified)

Select one only.

 0% 1

 1–24% 2

 25 - 49% 3

 50 - 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

All

4.4. Which instrument(s) does your Healthy Start project use to screen children for socio-emotional development?

Select one per row.

	Use	Do Not use	No Response
a. Ages and Stages Questionnaires: Social-Emotional (ASQ:SE)	1 	2 	M
b. Brief Infant-Toddler Social Emotional Assessment (BITSEA)	1 	2 	M
c. Carey Temperament Scales (CTS)	1 	2 	M
d. Greenspan Social-Emotional Growth Chart	1 	2 	M
e. Temperament and Atypical Behavior Scale (TABS), TABS Screener	1 	2 	M
f. Other instrument (specify): __________________________	1 	2 	M

all

4.5. In which of the following ways does your Healthy Start project link women to mental and behavioral health services?

Select one per row.

	Yes	No	No Response
a. Employs mental and behavior health staff who provide mental health services on site.	1 	2 	M
b. Partner with agencies in the community that provide mental and behavioral health services.	1 	2 	M
c. Refer participants to non-partner agencies in the community	1 	2 	M
d. Some other means of linking women to mental health services (Specify)________________________________________	1 	2 	M

all

4.6. In which of the following ways does your Healthy Start project link children to mental and behavioral health services?

Select one per row.

	Yes	No	No Response
a. Employs mental and behavior health staff who provide mental health services on site.	1 	2 	M
b. Partner with agencies in the community that provide mental and behavioral health services.	1 	2 	M
c. Refer participants to non-partner agencies in the community	1 	2 	M
d. Some other means of linking children to mental health services (Specify)__________________________________________	1 	2 	M

4b. TRAUMA INFORMED CARE

The next questions ask about how your Healthy Start project delivers trauma informed care to participants and their families. Trauma informed care is defined as a family-and-child-service approach that is welcoming and appropriate for individuals with ACE or toxic stress.

all

4.7. Does your Healthy Start project assess participating children for adverse childhood experiences (ACE) such as abuse, neglect, and violence? (NHSPS 3.41 modified)

 Yes 1

 No 0 SKIP TO 4.10

NO RESPONSE M SKIP TO 4.10

4.7 = 1

4.8. Does your Healthy Start project have a set of written procedures for assessing ACE scores? (NHSPS 3.44)

 Yes 1

 No 0 SKIP TO 4.10

NO RESPONSE M SKIP TO 4.10

4.8 = 1

4.9. Do the written procedures give guidance on appropriate follow-up actions in cases of suspected child abuse or neglect? (NHSPS 3.46)

 Yes 1

 No 0

NO RESPONSE M

all

4.10. Does your Healthy Start project use a standard or validated tool to screen for fetal alcohol spectrum disorders (FASD)?

 Yes 1

 No 0 SKIP TO 4.12

NO RESPONSE M SKIP TO 4.12

4.10 = 1

4.11. Which screening tool(s) does your Healthy Start project use to screen for fetal alcohol spectrum disorders (FASD)?

Select all that apply

 AUDIT 1

 CAGE 2

 T-ACE 3

 IHR 5 P’S 4

 Other screening tool (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

4.12. Does your Healthy Start project employ or contract with staff who can provide trauma informed care?

 Yes 1

 No 0

NO RESPONSE M

all

4.13. Does your Healthy Start project formally partner with agencies in the community to which you can refer participants for trauma informed care?

 Yes 1

 No 0

NO RESPONSE M

4c. PROMOTE FAMILY AND FATHER INVOLVEMENT

The next questions ask about how your Healthy Start project promotes family and father involvement in your project activities.

ALL

4.14. Does your Healthy Start project encourage male involvement in project services or activities? (NHSPS 2.24)

 Yes 1

 No 0

NO RESPONSE M

ALL

4.15. Does your Healthy Start project encourage other family member involvement in project services or activities? (NHSPS 2.24)

 Yes 1

 No 0

NO RESPONSE M

4.14 = 1 or 4.15 = 1

4.16. Which of the following activities are participants’ partners and/or family members invited to attend? (NHSPS 2.25 modified)

Select one per row.

	Partners/Family Invited to Attend	Partners/Family Not Invited to Attend	No Response
a. Health education classes or events	1 	2 	M
b. Home visits	1 	2 	M
c. Outreach activities	1 	2 	M
d. Community Action Network (CAN) meetings	1 	2 	M
e. Sessions to develop reproductive life plan	1 	2 	M
f. Sessions to develop written service plan	1 	2 	M
g. Other involvement (specify): ____________________________	1 	2 	M

all

4.17. During [GRANT YEAR], how many men were involved in your Healthy Start project activities? Your best estimate is fine (NHSPS 3.2)

Total number of men

(RANGE 0–1000)

NO RESPONSE M

all

4.18. What percentage of these men are partners (or fathers of children) of enrolled female participants? Your best estimate is fine. (NHSPS 3.3 modified)

Select one only.

 0% 1

 1–24% 2

 25 - 49% 3

 50 - 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

all

4.19. How are males recruited? (NHSPS 3.16)

Select all that apply

 Community outreach 1

 Court referral or mandate 2

 Referrals from other service providers 3

 Referrals through female partner 4

 Other method (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

4.20. What strategies does your Healthy Start project use to facilitate male retention? (NHSPS 3.17)

Select all that apply

 Frequent contact and follow-up with men 1

 Incentives (such as raffles, coupons, prizes, and gifts) 2

 Offer community-based events 3

 Offer services or programs specific to male needs 4

 Provision of child care 5

 Financial assistance (e.g., food vouchers, merchandise) 6

 Provision of transportation 7

 Community engagement in Healthy Start 8

 Other strategy (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

4.21. Does your Healthy Start project use a specific male involvement curriculum? (NHSPS 3.10)

 Yes 1

 No 0 SKIP TO 4.23

NO RESPONSE M SKIP TO 4.23

4.21 = 1

4.22. What male involvement curriculum does your Healthy Start project use?

curriculum

(STRING 1000)

NO RESPONSE M

all

4.23. During [GRANT YEAR], what services were offered to men? (NHSPS 3.8 modified)

Select one per row.

	Yes	No	No Response
a. Case management services	1 	2 	M
b. Clinical services	1 	2 	M
c. Court advocacy	1 	2 	M
d. Education assistance training (e.g., preparation for GED)	1 	2 	M
e. Health education	1 	2 	M
f. Insurance enrollment assistance services	1 	2 	M
g. Job readiness/employment services	1 	2 	M
h. Mental health services	1 	2 	M
i. Parenting Education	1 	2 	M
j. Other service (specify): ________________________________	1 	2 	M

all

4.24. Are services offered to men as a males-only program (for example, men meeting at separate time or have their own classes apart from participating women and children)? (NHSPS 3.4)

 Yes 1

 No 0 SKIP TO 4.27

NO RESPONSE M SKIP TO 4.27

4.24 = 1 AND any 4.23a through 4.23j = 1

4.25. Which of the following services does your Healthy Start project offer as part of the males-only program? How often are these services offered? (NHSPS 3.5)

Select all that apply per row.

[ONLY DISPLAY SERVICES SELECTED YES IN 4.23]	Weekly	Every Other Week	Every Month	Every 2 Months	Every 3 Months	Every 6 Months	Every 12 Months	Other	No response
a. Case management services	1 	2 	3 	4 	5 	6	7 	8 	M
b. Clinical services	1 	2 	3 	4 	5 	6	7 	8 	M
c. Court advocacy	1 	2 	3 	4 	5 	6	7 	8 	M
d. Education assistance training (e.g., preparation for GED)	1 	2 	3 	4 	5 	6	7 	8 	M
e. Health education	1 	2 	3 	4 	5 	6	7 	8 	M
f. Insurance enrollment assistance services	1 	2 	3 	4 	5 	6	7 	8 	M
g. Job readiness/ employment services	1 	2 	3 	4 	5 	6	7 	8 	M
h. Mental health services	1 	2 	3 	4 	5 	6	7 	8 	M
i. Parenting education	1 	2 	3 	4 	5 	6	7 	8 	M
j. [FILL IN RESPONSE FROM 4.23j]	1 	2 	3 	4 	5 	6	7 	8 	M

4.24 = 1

4.26. For how long do men typically receive males-only services through your Healthy Start project? (NHSPS 3.7 modified)

If duration is tied to the pregnancy status of the participant, please indicate this in the Other field.
Select one only.

 Less than 3 months 1

 4- 6 months 2

 7-11 months 3

 12 months (one year) 4

 13-23 months 5

 24 months (2 years) or more 6

 Other duration (specify) 99

Specify (STRING 0–1000)

 There is no specific time period 999

NO RESPONSE M

4d. IMPROVE PARENTING

The following questions ask about your Healthy Start project’s parenting education activities.

For the following questions, we define parenting education as all classes, support groups, or one-on-one education sessions that were provided to parents about infant/child care and development. To qualify as a parenting education activity, the activity must be specifically designed for the purposes of improving parenting knowledge and skills (i.e., parenting tips provided during routine baby exams do not constitute parenting education).

all

4.27. Which of the following models do your Healthy Start project or partner agencies use for parenting education?

Select one per row.

	Yes	No	No Response
a. Effective Black Parenting Program	1 	2 	M
b. Legacy for Children	1 	2 	M
c. Parents as Teachers	1 	2 	M
d. STAR Parenting	1 	2 	M
e. Strengthening Families	1 	2 	M
f. Systematic Training for Effective Parenting (STEP)	1 	2 	M
g. The Incredible Years	1 	2 	M
h. The Nurturing Parent Programs	1 	2 	M
i. Touchpoints	1 	2 	M
j. Triple P – Positive Parenting Program	1 	2 	M
k. Other model (Specify): ______________________________	1 	2 	M

all

4.28. How does your Healthy Start project or partner deliver parenting education services to participants?

Select one per row.

	Yes	No	No Response
a. Parent education classes	1 	2 	M
b. Home visiting program designed to educate parents	1 	2 	M
c. One-on-one education sessions	1 	2 	M
d. Parenting support groups	1 	2 	M
e. Other (specify): ___________________________________	1 	2 	M

all

4.29. During [GRANT YEAR], what percentage of women participating in your Healthy Start project attended parenting support groups?

Select one only.

 0% 1

 1–24% 2

 25 - 49% 3

 50 - 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

all

4.30. During [GRANT YEAR], what percentage of women participating in your Healthy Start project received one-on-one parenting education services?

Select one only.

 0% 1

 1–24% 2

 25 - 49% 3

 50 - 74% 4

 75 - 99% 5

 100% 6

NO RESPONSE M

SECTION 5. ACHIEVE COLLECTIVE IMPACT

The questions in Section 5 ask about what your Healthy Start project is doing to achieve collective impact in your community.

5a. DEVELOP AND USE COMMUNITY ACTION NETWORK

The next questions are about your Healthy Start project’s Community Action Network (CAN)

all

5.1. During [GRANT YEAR], how many individuals actively participated in the Community Action Network (CAN)?

Number of active CAN members

(RANGE 0–1000)

NO RESPONSE M

all

5.2. During [GRANT YEAR], how many organizations were represented on the CAN?

Number of organizations

(RANGE 0–1000)

NO RESPONSE M

ALL

5.3. Which types of organizations and groups are included in the active membership of the CAN?

By active membership, we mean members that attend at least half of the CAN’s meetings. (NHSPS 5.34 modified)

Select one per row.

	Yes	No	No response
a. Academic institutions	1 	2 	M
b. Community members	1 	2 	M
c. Community-based organizations	1 	2 	M
d. Faith-based organizations	1 	2 	M
e. Healthy Start staff	1 	2 	M
f. Local government	1 	2 	M
g. Other providers	1 	2 	M
h. Private agencies or organizations (not community based)	1 	2 	M
i. Healthy Start consumers (i.e., recipient of Healthy Start services)	1 	2 	M
j. Providers contracting with the Healthy Start project	1 	2 	M
k. State government	1 	2 	M
l. Other (specify): __________________________	1 	2 	M

all

5.4. What are the main purpose(s)of your Healthy Start project’s CAN? (NHSPS 5.35 modified)

Select all that apply

 Bring together potential partners and enhance collaboration 1

 Change maternal and child health practices in the target
community or system 2

 Change maternal and child health policy in the state 3

 Fulfill requirements of grant guidance 4

 Oversee Healthy Start project operations 5

 Share information with the community and raise awareness
of maternal and child health issues 6

 Work toward goals of the strategic action plan 7

 Other purpose not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

5.5. What types of communications activities are conducted by the CAN and how often? (NHSPS 5.37)

Select one per row.

	Annually	Semi-annually	Quarterly	Other	Event Not Conducted by the CAN	No Response
a. Conferences	1 	2 	3 	4 	4 	M
b. In-person meetings with members	1 	2 	3 	4 	4 	M
c. Public Forums	1 	2 	3 	4 	4 	M
d. Training	1 	2 	3 	4 	4 	M
e. Virtual meetings/ webinars with members	1 	2 	3 	4 	4 	M
f. Other (specify): _____________________	1 	2 	3 	4 	4 	M

All

5.6. Collaboration can be defined as any joint planning, service coordination, cost-sharing initiatives, or other activities in which your organizations worked together toward a common goal.

From the list of CAN members below, please select up to 10 organizations with which your Healthy Start project collaborated during the past 12 months.

If your Healthy Start project collaborated with more than 10 organizations, select the 10 with which [ORG NAME] collaborated most closely.

PROGRAMMER: INSERT DROP DOWN FIELDS CAN MEMBER 1–10

▼

CAN Member 1

▼

CAN Member 2

▼

CAN Member 3

▼

CAN Member 4

▼

CAN Member 5

▼

CAN Member 6

▼

CAN Member 7

▼

CAN Member 8

▼

CAN Member 9

▼

CAN Member 10

where response(s) selected in 5.6

5.7. During the past 12 months, in which of the following ways did your Healthy Start project formally and/or informally partner with other CAN members outside of CAN activities? (CVC Survey B1 modified)

Select all that apply per row.

[ONLY DISPLAY CAN MEMBERS SELECTED IN 5.6]	Signed Formal Memorandum of Understanding (MOU) with Organization	Met with Organization for Joint Planning Outside of CAN Meetings	Participated in Collaborative Group or Working Group with Organization in Addition to the CAN	Submitted Joint Grant Proposal	No Response
a. [FILL 5.6_1]	1 	2 	3 	4 	M
b. [FILL 5.6_2]	1 	2 	3 	4 	M
c. [FILL 5.6_3]	1 	2 	3 	4 	M
d. [FILL 5.6_4]	1 	2 	3 	4 	M
e. [FILL 5.6_5]	1 	2 	3 	4 	M
f. [FILL 5.6_6]	1 	2 	3 	4 	M
g. [FILL 5.6_7]	1 	2 	3 	4 	M
h. [FILL 5.6_8]	1 	2 	3 	4 	M
i. [FILL 5.6_9]	1 	2 	3 	4 	M
j. [FILL 5.6_10]	1 	2 	3 	4 	M

where response(s) selected in 5.6

5.8. During the past 12 months, in which of the following ways did your Healthy Start project collaborate with the other CAN members regarding services for women, children, and their families?

Select all that apply per row.

[ONLY DISPLAY CAN MEMBERS SELECTED IN 5.6]	Made Referrals to Organization	Received Referrals from Organization	Shared/Used the Same Data System	No Response
a. [FILL 5.6_1]	1 	2 	3 	M
b. [FILL 5.6_2]	1 	2 	3 	M
c. [FILL 5.6_3]	1 	2 	3 	M
d. [FILL 5.6_4]	1 	2 	3 	M
e. [FILL 5.6_5]	1 	2 	3 	M
f. [FILL 5.6_6]	1 	2 	3 	M
g. [FILL 5.6_7]	1 	2 	3 	M
h. [FILL 5.6_8]	1 	2 	3 	M
i. [FILL 5.6_9]	1 	2 	3 	M
j. [FILL 5.6_10]	1 	2 	3 	M

where response(s) selected in 5.6

5.9. During the past 12 months, which of the following activities did your Healthy Start project engage in with other CAN members? (CVC Survey B2 modified)

Select all that apply per row.

[ONLY DISPLAY CAN MEMBERS SELECTED IN 5.6]	Participated in Joint Training with Organization	Organized/ Imple-mented Grassroots Activities (e.g., Health Fair or Other Community Events)	Developed Joint Program Materials	Met with Policymaker or Attended Public Meeting or Hearing with the Organization	Developed Media Messages/ Organized Media Events	Assessed or “Mapped” Community Needs Using Data	No Response
a. [FILL 5.6_1]	1 	2 	3 	4 	5 	6 	M
b. [FILL 5.6_2]	1 	2 	3 	4 	5 	6 	M
c. [FILL 5.6_3]	1 	2 	3 	4 	5 	6 	M
d. [FILL 5.6_4]	1 	2 	3 	4 	5 	6 	M
e. [FILL 5.6_5]	1 	2 	3 	4 	5 	6 	M
f. [FILL 5.6_6]	1 	2 	3 	4 	5 	6 	M
g. [FILL 5.6_7]	1 	2 	3 	4 	5 	6 	M
h. [FILL 5.6_8]	1 	2 	3 	4 	5 	6 	M
i. [FILL 5.6_9]	1 	2 	3 	4 	5 	6 	M
j. [FILL 5.6_10]	1 	2 	3 	4 	5 	6 	M

all

5.10. The following questions are about your Healthy Start project’s experiences as a member of the CAN. Please indicate your agreement with the following statements on a scale from “Strongly Disagree” to “Strongly Agree.” (Wilder)

	Select one per row.
	Strongly Disagree	Disagree	Neutral/No Opinion	Agree	Strongly Agree	No Response
Collaboration in the community
a. Agencies/organizations in our community have a history of working together. (1)	1 	2 	3 	4 	5 	M
b. Trying to solve problems through collaboration has been common in this community. It’s been done a lot before. (2)	1 	2 	3 	4 	5 	M
c. Others (in this community) who are not a part of the CAN would generally agree that the organizations involved in the CAN are the “right” organizations to make this work. (4)	1 	2 	3 	4 	5 	M
d. The political and social climate seems to be “right” for starting a collaborative project like the CAN. (5)	1 	2 	3 	4 	5 	M
Resources
e. The CAN encourages effective and equitable allocation of limited resources.	1 	2 	3 	4 	5 	M
f. The CAN is able to adapt to changing conditions, such as fewer funds than expected, changing political climate, or change in leadership. (22)	1 	2 	3 	4 	5 	M
Representation
g. The people involved in the CAN represent a cross section of those who have a stake in what we are trying to accomplish. (9)	1 	2 	3 	4 	5 	M
h. All the organizations that we need to be members of the CAN have become members of the CAN. (10)	1 	2 	3 	4 	5 	M
i. The provider membership on the CAN is culturally representative of the target community.	1 	2 	3 	4 	5 	M
Roles and responsibilities
j. People in the CAN have a clear sense of their roles and responsibilities. (20)	1 	2 	3 	4 	5 	M
k. There is a clear process for making decisions among the members in the CAN. (21)	1 	2 	3 	4 	5 	M
Commitment
l. The organizations that belong to the CAN invest the right amount of time in our collaborative efforts. (13)	1 	2 	3 	4 	5 	M
m. The level of commitment among the CAN members is high. (15)	1 	2 	3 	4 	5 	M
n. The CAN has tried to take on the right amount of work at the right pace. (24)	1 	2 	3 	4 	5 	M
Communication
o. People in the CAN communicate openly with one another. (26)	1 	2 	3 	4 	5 	M
p. I am informed as often as I should be about what goes on in the CAN. (27)	1 	2 	3 	4 	5 	M
q. The leaders of the CAN disseminate information using a variety of modalities and technologies.	1 	2 	3 	4 	5 	M
r. The people who lead the CAN communicate well with the members. (28)	1 	2 	3 	4 	5 	M
s. Communication among the people in the CAN happens both at formal meetings and in informal ways. (29)	1 	2 	3 	4 	5 	M
Mutual respect, understanding, and trust
t. People involved in the CAN always trust one another. (7)	1 	2 	3 	4 	5 	M
u. I have a lot of respect for the other people involved in the CAN. (8)	1 	2 	3 	4 	5 	M
v. My organization benefits from being involved in the CAN (11)	1 	2 	3 	4 	5 	M
Goals	1 	2 	3 	4 	5 	M
w. People in the CAN know and understand our goals. (32)	1 	2 	3 	4 	5 	M
x. People in the CAN have established reasonable goals. (33)	1 	2 	3 	4 	5 	M
y. What we are trying to accomplish as the CAN would be difficult for any single organization to accomplish by itself. (36)	1 	2 	3 	4 	5 	M

where response(s) selected in 5.6

5.11. During the past 12 months, how closely did your Healthy Start project work with each of the other organizations listed below? (Living Cities 11a modified)

We define “closely” as a range between not working together at all to working closely with another organization on joint activities (from “1” to “5”). Examples of such activities might include joint planning, service coordination, cost sharing, or other activities working toward a common goal.

Select one per row.

[ONLY DISPLAY CAN MEMBERS SELECTED IN 5.6]	We Do Not Work Together at All				We Closely Collaborate	No Response
a. [FILL 5.6_1]	1 	2 	3 	4 	5 	M
b. [FILL 5.6_2]	1 	2 	3 	4 	5 	M
c. [FILL 5.6_3]	1 	2 	3 	4 	5 	M
d. [FILL 5.6_4]	1 	2 	3 	4 	5 	M
e. [FILL 5.6_5]	1 	2 	3 	4 	5 	M
f. [FILL 5.6_6]	1 	2 	3 	4 	5 	M
g. [FILL 5.6_7]	1 	2 	3 	4 	5 	M
h. [FILL 5.6_8]	1 	2 	3 	4 	5 	M
i. [FILL 5.6_9]	1 	2 	3 	4 	5 	M
j. [FILL 5.6_10]	1 	2 	3 	4 	5 	M

where response(s) selected in 5.6

5.12. Overall, how productive is your Healthy Start project’s current working relationship with each of the organizations listed below? (CVC Survey B3 modified)

A productive working relationship is one in which you feel you are making progress toward a goal.

Select one per row.

[ONLY DISPLAY CAN MEMBERS SELECTED IN 5.6]	Not Productive	Somewhat Productive	Very Productive	Can’t Assess	No Response
a. [FILL 5.6_1]	1 	2 	3 	4 	M
b. [FILL 5.6_2]	1 	2 	3 	4 	M
c. [FILL 5.6_3]	1 	2 	3 	4 	M
d. [FILL 5.6_4]	1 	2 	3 	4 	M
e. [FILL 5.6_5]	1 	2 	3 	4 	M
f. [FILL 5.6_6]	1 	2 	3 	4 	M
g. [FILL 5.6_7]	1 	2 	3 	4 	M
h. [FILL 5.6_8]	1 	2 	3 	4 	M
i. [FILL 5.6_9]	1 	2 	3 	4 	M
j. [FILL 5.6_10]	1 	2 	3 	4 	M

ALL

5.13. In your organization’s view, what are the three main goals of the CAN? (Living Cities 13 modified)

Goal #1

Goal #2

Goal #3

5.13_1 populated

5.14a. Please indicate how effective the initiative currently is in working toward [FILL IN GOAL FROM 5.13_1]. (Living Cities 13 modified)

Select one only.

 Not effective 1

 Somewhat effective 2

 Very effective 3

 Don’t know 4

NO RESPONSE M

5.13_2 populated

5.14b. Please indicate how effective the CAN currently is in working toward [FILL IN GOAL FROM 5.13_2]. (Living Cities 13 modified)

Select one only.

 Not effective 1

 Somewhat effective 2

 Very effective 3

 Don’t know 4

NO RESPONSE M

5.13_3 populated

5.14c. Please indicate how effective the CAN currently is in working toward [FILL IN GOAL FROM 5.13_3]. (Living Cities 13 modified)

Select one only.

 Not effective 1

 Somewhat effective 2

 Very effective 3

 Don’t know 4

NO RESPONSE M

ALL

5.15. What do you feel are the top five barriers the CAN faces in achieving its goals?

Select up to five.

• Competing agendas of member organizations 1

• Insufficient resources in the state or community to support our goals 2

• Insufficient staff time dedicated to assisting the consortium in its efforts 3

• Irregular attendance at consortium meetings by key members 4

• Lack of collaboration/cooperation from necessary partners
  and stakeholders 5

• Lack of history of collaborative effort among health and
  service providers in our community 6

• Lack of participant involvement 7

• Lack of resources for consortium activities 8

• Lack of strategic plan for the consortium 9

• Lack of strong consortium leadership 10

• Unstable relationships among consortium members 11

• Unsupportive political climate 12

• Other (specify) 99

Specify (STRING 500)

all

5.16. To what extent has the CAN focused on improving the following community outcomes:

Select one per row.

	CAN Does Not Focus on This	CAN Focuses on This to Some Extent	CAN Focuses on This to a Great Extent	Do Not Know	No Response
a. Capacity to address social determinants of health	1 	2 	3 	4 	M
b. Community mobilization and involvement	1 	2 	3 	4 	M
c. Data systems to coordinate and provide care across organizations	1 	2 	3 	4 	M
d. Integration of care	1 	2 	3 	4 	M
e. Maternal, child, and family access to care and services	1 	2 	3 	4 	M
f. Navigation and appropriate care delivery across health and social service systems	1 	2 	3 	4 	M
g. Processes to support access to comprehensive care	1 	2 	3 	4 	M
h. Stability of families in the community	1 	2 	3 	4 	M

all

5.17. To what extent has the CAN has made an impact on each of the following community outcomes:

Select one per row.

	CAN Has Made No Impact	CAN Has Made Some Impact	CAN Has Made Major Impact	Do Not Know	No Response
a. Capacity to address social determinants of health	1 	2 	3 	4 	M
b. Community mobilization and involvement	1 	2 	3 	4 	M
c. Data systems to coordinate and provide care across organizations	1 	2 	3 	4 	M
d. Integration of care	1 	2 	3 	4 	M
e. Maternal, child, and family access to care and services	1 	2 	3 	4 	M
f. Navigation and appropriate care delivery across health and social service systems	1 	2 	3 	4 	M
g. Processes to support access to comprehensive care	1 	2 	3 	4 	M
h. Stability of families in the community	1 	2 	3 	4 	M

5b. COMMUNITY SOCIAL CAPITAL AND EMPOWERMENT

The next questions ask about how the social capital of the community in which your Healthy Start project operates and the project’s influence in the community.

Social Capital

all

5.18. For each of the following statements, please indicate whether you strongly agree, agree, disagree or strongly disagree regarding the community in which your Healthy Start project is located.

	Select one per row.
	Strongly Agree	Agree	Disagree	Strongly Disagree	No Response
Trust
a. People can depend on each other in this community. (SHAPE 2002 13a)	1 	2 	3 	4 	M
b. People know they can get help from the community if they are in trouble. (SHAPE 2002 13c)	1 	2 	3 	4 	M
c. Generally speaking, most people in the community can be trusted. (SOCAT Household 5B10 modified)	1 	2 	3 	4 	M
d. Differences between people living in the community (such as differences in education, wealth, race, religious beliefs, or ethnic background) tend to divide the community. (SOCAT Household 4C1 modified)	1 	2 	3 	4 	M
Community Participation and Mobilization
e. People in the community are inclined to attend local events like school concerts, religious gatherings, or neighborhood fairs.(SHAPE 2002 12 modified)	1 	2 	3 	4 	M
f. Individuals often join together with other people in the community to address a common issue. (SOCAT Household 4D3 modified)	1 	2 	3 	4 	M
g. Most people feel accepted as a member of the community. (SOCAT Household 5B10i modified)	1 	2 	3 	4 	M
Access
h. People in the community often experience difficulty accessing services like health care or social services.	1 	2 	3 	4 	M
i. It is common for people in the community to be excluded from access to services due to income level, gender, race, ethnicity, religious beliefs, or education level.	1 	2 	3 	4 	M
j. People in the community have access to phone and Internet, either through personal devices or public sources (like libraries).	1 	2 	3 	4 	M
Well-being in the Community
k. This community is a good place to raise children. (SHAPE 2002 13d)	1 	2 	3 	4 	M
l. People here look out mainly for the welfare of their own families, and they are not much concerned with community welfare. (SOCAT Community 1.19)	1 	2 	3 	4 	M
m. Residents generally feel secure living in this community. (SHAPE 2002, 13b modified)	1 	2 	3 	4 	M

all

5.19. Thinking about community issues (such as job and housing availability, safety and security, and the environment), in your opinion, in the past three years the overall quality of life of the people living in this community has . . . (Social Capital Assessment Tool Community Questionnaire, 1.13 modified)

Select one only.

 Improved 1

 Worsened 2

 Remained the same 3

NO RESPONSE M

5c. STRATEGIC ACTION PLAN

The next section is about your Healthy Start project’s strategic action plan.

all

5.20. Does your Healthy Start project have a strategic action plan for collaborating with organizations in the community and state? (NHSPS 5.4 modified)

 Yes 1

 No 0 SKIP TO 5.24

NO RESPONSE M SKIP TO 5.24

5.20 = 1

5.21. Is your Healthy Start project’s strategic action plan specific to the Healthy Start project, or is it connected to another community strategic plan? (NHSPS 5.5 and 5.6 modified)

 Specific to Healthy Start Project 1 SKIP TO 5.23

 Connected to another community or child health plan 2

NO RESPONSE M SKIP TO 5.23

5.21 = 2

5.22. To which plan(s) is it connected? (NHSPS 5.7 modified)

Select all that apply

 Title V MCH block grant 1

 Local public health department 2

 Other plan (specify) 99

Specify (STRING 1000)

NO RESPONSE M

5.20 = 1

5.23. Who was involved in the development of the strategic action plan? (NHSPS 5.8 modified)

Select one per row.

	Yes	No	No Response
Healthy Start CAN or subcommittee of the CAN	1 	2 	M
Healthy Start staff	1 	2 	M
Key community partners	1 	2 	M
Local government	1 	2 	M
Local health department	1 	2 	M
Local Title V grantee	1 	2 	M
Participants	1 	2 	M
State Title V agency	1 	2 	M
Other (specify): ______________________________	1 	2 	M

5d. COMMUNITY EMPOWERMENT

The next questions ask about the impact your Healthy Start project has in your community.

ALL

5.24. Is your Healthy Start project involved in community-wide collaborative efforts related to: (NHSPS 5.23)

Select one per row.

	Yes	No	No Response
a. Breastfeeding	1 	2 	M
b. Employment	1 	2 	M
c. Family planning	1 	2 	M
d. Healthy families	1 	2 	M
e. Healthy weight	1 	2 	M
f. Housing	1 	2 	M
g. Improved birth outcomes	1 	2 	M
h. Insurance enrollment	1 	2 	M
i. Other social services	1 	2 	M
j. Smoking and tobacco cessation	1 	2 	M
k. Other (specify): ____________________________________	1 	2 	M

5e. PARTNERSHIPS

The next questions are about your Healthy Start project’s other partnerships at the state and national level.

ALL

5.25. Does your Healthy Start project have any partnerships with any of the initiatives listed below?

Select one per row.

	Yes	No	No Response
a. Collaborative Innovation and Improvement Network (CoIIN)	1 	2 	M
b. Early Childhood Program	1 	2 	M
c. Early Head Start Program	1 	2 	M
d. Family/Patient Centered Medical Home Program	1 	2 	M
e. Family-to-Family Health Information Center	1 	2 	M
f. Healthy Tomorrows	1 	2 	M
g. National Preconception Health and Health Care (PCHHC) Initiative	1 	2 	M
h. Strong Start Programs	1 	2 	M
i. Text4baby	1 	2 	M
j. Title V Maternal and Child Health Programs	1 	2 	M
k. Title X Family Planning Programs	1 	2 	M
l. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)	1 	2 	M

any 5.25a through 5.25l = 1

5.26. For each of the following initiatives, indicate the purpose(s) of the partnership below.

Select all that apply per row.

[ONLY DISPLAY GRANTS SELECTED IN 5.25]	Information Sharing	Pooling Resources	Joint Training	Educating Policy Makers	Working with State Agencies	Other (Specify)	No Response
a. Collaborative Innovation and Improvement Network (CoIIN)	1 	2 	3 	4 	5 	6 	M
b. Early Childhood Program	1 	2 	3 	4 	5 	6 	M
c. Early Head Start Program	1 	2 	3 	4 	5 	6 	M
d. Family/Patient Centered Medical Home Program	1 	2 	3 	4 	5 	6 	M
e. Family-to-Family Health Information Center	1 	2 	3 	4 	5 	6 	M
f. Healthy Tomorrows	1 	2 	3 	4 	5 	6 	M
g. National Preconception Health and Health Care (PCHHC) Initiative	1 	2 	3 	4 	5 	6 	M
h. Strong Start Programs	1 	2 	3 	4 	5 	6 	M
i. Text4baby	1 	2 	3 	4 	5 	6 	M
j. Title V Maternal and Child Health Programs	1 	2 	3 	4 	5 	6 	M
k. Title X Family Planning Programs	1 	2 	3 	4 	5 	6 	M
l. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)	1 	2 	3 	4 	5 	6 	M

all

5.27. Describe the relationship between your Healthy Start project and the state Title V agency.

Select all that apply

 State Title V agency is the Healthy Start grantee 1

 Healthy Start project and state Title V are housed in the same agency 2

 Management is shared between Healthy Start project and state Title V agency 3

 State Title V funds some Healthy Start programming or services 4

 Healthy Start project has an informal relationship with state Title V agency 5

 Healthy Start project does not have a relationship with state Title V agency 6 SKIP TO 5.30

 Other relationship (specify) 99

Specify (STRING 1000)

NO RESPONSE M SKIP TO 5.30

5.27 ne 6 or no response

5.28. How does your Healthy Start project benefit from coordinating with the state Title V agency? (NHSPS 5.12)

Select all that apply

 State Title V helps coordinate care for our participants 1

 State Title V helps increase our visibility in policy arenas 2

 State Title V helps with efforts to advocate for Healthy Start
target populations 3

 State Title V provides data and other information for needs
assessment 4

 State Title V provides funds or in-kind contributions that helped
sustain Healthy Start initiatives 5

 State Title V provides resource materials for health education programs 6

 State Title V provides training for staff 7

 There are no perceived benefits 8

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

5.27 ne 6 or no response

5.29. How does the state Title V agency benefit from coordinating with your Healthy Start project? (NHSPS 5.13)

Select all that apply

 Healthy Start makes policy/funding recommendations to the
state Title V agency on important policy and funding issues 1

 Healthy Start projects could be replicated by the state Title V agency 2

 Healthy Start is a local partner that could implement and/or
augment state Title V initiatives and programs on the local level 3

 Healthy Start provides data to Title V 4

 Healthy Start provides the state Title V agency with a community
perspective on issues and problems 5

 Healthy Start’s local needs assessment data are used by the state Title V
agency in its own needs assessment for the state block grant 6

 The state Title V agency does not perceive any benefit from
coordination with Healthy Start 7

 Other benefit not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

5.30. Does your Healthy Start project participate in any formal associations with other Healthy Start grantees (not including the National Healthy Start Association)? (NHSPS 5.14)

 Yes 1

 No 0 SKIP TO 6.1

NO RESPONSE M SKIP TO 6.1

5.30 = 1

5.31. What is the purpose(s) of this association(s)? (NHSPS 5.15)

Select one per row.

	Yes	No	No Response
Educating policymakers	1 	2 	M
Evaluation Information sharing	1 	2 	M
Joint training	1 	2 	M
Pooling resources	1 	2 	M
Working with state agencies	1 	2 	M
Other purpose (specify): _______________________	1 	2 	M

5.30 = 1

5.32. To date, what benefits have resulted from the association(s) with other Healthy Start grantees? (NHSPS 5.16)

Select all that apply

 Enhanced ability to work with state policymakers on common issues 1

 Expanded resources available to use for common activities such as
evaluation, training, and health education 2

 Increased access to information 3

 No benefits have resulted to date 4

 Other benefit (specify) 99

Specify (STRING 1000)

NO RESPONSE M

SECTION 6. Increase Accountability Through Quality Improvement, Performance Monitoring, and Evaluation

The questions in Section 6 ask about what your Healthy Start project is doing to increase accountability. Questions will focus on the following activities: quality improvement efforts, performance monitoring, and evaluation.

6a. QUALITY IMPROVEMENT

The next questions ask about your Healthy Start project’s quality improvement efforts.

all

6.1. Does your Healthy Start project have a plan in place to initiate and track quality improvement?

 Yes 1

 No 0 SKIP TO 6.3

NO RESPONSE M SKIP TO 6.3

6.1 = 1

6.2. Who helped develop your Healthy Start project’s quality improvement plan?

Select one per row.

	Yes	No	No Response
CAN members	1 	2 	M
Healthy Start staff	1 	2 	M
Other local partners in community	1 	2 	M
Other partners at the state level	1 	2 	M
Participants	1 	2 	M
Other (specify): ______________________________	1 	2 	M

ALL

6.3. Which of the following are priority areas for quality improvement?

Select one per row.

	Yes	No	No Response
a. Assessment of policies	1 	2 	M
b. Strategic planning	1 	2 	M
c. Program improvement (efficiency/effectiveness; processes and procedures)	1 	2 	M
d. Improved collaboration with partners/leveraging resources	1 	2 	M
e. Other priority not listed above (specify): ________________________	1 	2 	M

all

6.4. What measures does your Healthy Start project use to track quality improvement?

Select all that apply

 Discretionary Grant Information System (DGIS) reported measures 1

 Healthy Start performance measures/benchmarks 2

 Healthcare Effectiveness Data and Information Set (HEDIS) measures 3

 Other measure not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

6.5. When your Healthy Start project implements quality improvement initiatives, does your Healthy Start project offer:

Select all that apply

 Technical assistance for community partners, providers, and agencies 1

 Technical assistance to Healthy Start staff 2

 Training for community partners, providers, and agencies 3

 Training for Healthy Start staff 4

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

ALL

6.6. Does your Healthy Start project have a dedicated staff member or group of staff members responsible for tracking quality improvement initiatives?

 Yes 1

 No 0 SKIP TO 6.8

NO RESPONSE M SKIP TO 6.8

6.6 = 1

6.7. What types of people are responsible for . . .

Select all that apply per row.

TYPES OF STAFF MEMBERS	Case Managers	Adminis-trative Staff	Evaluation Staff or Contractors	Data/ IT Staff	Consumers	Other (Specify Type of Staff Member in Box)	No Response
a. Developing and planning quality improvement initiatives?	1 	2 	3 	4 	5 	6 	M
b. Implementing quality improvement initiatives?	1 	2 	3 	4 	5 	6 	M
c. Tracking quality improvement initiatives?	1 	2 	3 	4 	5 	6 	M
d. Disseminating findings from quality improvement initiatives?	1 	2 	3 	4 	5 	6 	M

6b. PERFORMANCE MONITORING

The next questions ask about your Healthy Start’s performance monitoring efforts.

all

6.8. Does your Healthy Start project employ its own staff or have a contract with an external organization to collect program data?

Select all that apply

 Own staff 1

 External contractor 2

 We do not collect program data 3

 Other measure not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

6.9. Is there a data system in place that tracks each Healthy Start participant? (NHSPS 6.1)

 Yes 1

 No 0 SKIP TO 6.11

NO RESPONSE M SKIP TO 6.11

6.9 = 1

6.10. What system is used to collect participant-level data?

System

(STRING 1000)

NO RESPONSE M

all

6.11. Is participation tracked for the following services? (NHSPS 6.5 modified)

Select one per row.

	Yes	No	No Response
a. Case management services (including service coordination, referral follow-up, etc.)	1 	2 	M
b. Comprehensive needs/risk assessments	1 	2 	M
c. Developmental screenings for children	1 	2 	M
d. Father/male/partner involvement	1 	2 	M
e. Health education	1 	2 	M
f. Health Insurance outreach and enrollment services	1 	2 	M
g. Home visiting	1 	2 	M
h. Infant/children’s medical services	1 	2 	M
i. Linkage to medical home providers	1 	2 	M
j. Linkage to mental and behavioral health services	1 	2 	M
k. Parenting education services	1 	2 	M
l. Reproductive life planning services	1 	2 	M
m. Services that address toxic stress and adverse childhood experiences (ACE)	1 	2 	M
n. Women’s medical services	1 	2 	M
o. Other (specify): ___________________________________	1 	2 	M

6.9 = 1 and any 6.11a through 6.11o = 1

6.12. Are the data-tracking systems for Healthy Start services and participants linked? (NHSPS 6.7)

 Yes 1

 No 0

NO RESPONSE M

all

6.13. How frequently are data analyzed by your Healthy Start project? (NHSPS 6.9)

Select one only.

 Annually 1

 Semiannually 2

 Quarterly 3

 Monthly 4

 More often than once a month 5

 Other (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

6.14. For what purposes are data examined for your Healthy Start project? (NHSPS 6.10)

Select one per row.

	Yes	No	No Response
Grant writing	1 	2 	M
Media campaigns	1 	2 	M
Project evaluation	1 	2 	M
Project planning	1 	2 	M
Quality assurance	1 	2 	M
Quality/program improvement	1 	2 	M
Reporting to CAN	1 	2 	M
Required reporting (performance measures, impact reporting)	1 	2 	M
Other purpose not listed above (specify)	1 	2 	M

all

6.15. During [GRANT YEAR], did any of the following types of systems related to maternal and child health exist in your community? (NHSPS 6.40)

Select all that apply

 Fetal and Infant Mortality Review (FIMR) 1

 Maternal morbidity and mortality review (MMMR) 2

 Perinatal Periods of Risk (PPOR) 3

 Other (specify) 99

Specify (STRING 1000)

 No mortality reviews existed in our community during [GRANT YEAR] 999 SKIP TO 6.19

NO RESPONSE M

6.15 = 1, 2, 3, 99

6.16. During [GRANT YEAR], was Healthy Start data represented in these maternal and child health systems? (NHSPS 6.41)

 Yes 1

 No 0

NO RESPONSE M

6.15 = 1, 2, 3, 99

6.17. Does your Healthy Start project use data from any mortality reviews? (NHSPS 6.42)

 Yes 1

 No 0 SKIP TO 6.19

NO RESPONSE M SKIP TO 6.19

6.17 = 1

6.18. During [GRANT YEAR], how were mortality review data used by your Healthy Start project? (NHSPS 6.43)

Select all that apply

 To generate systems change goals 1

 To target outreach or health promotion 2

 To track mortality by age group, race/ethnicity, socioeconomic group,
and/or neighborhood 3

 Other use not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

6c. EVALUATION

The next questions ask about how your Healthy Start project’s evaluation activities.

all

6.19. Has your Healthy Start project ever conducted an evaluation of program activities? (NHSPS 6.36 modified)

 Yes 1

 No 0 SKIP TO 6.26

NO RESPONSE M SKIP TO 6.26

6.19 = 1

6.20. Which of the following activities were evaluated? (NHSPS 6.38 modified)

Select one per row.

	Evaluated activity	Did not evaluate activity	No Response
a. CAN efforts and initiatives	1 	2 	M
b. Case management services (including service coordination, referral follow-up, etc.)	1 	2 	M
c. Comprehensive needs/risk assessment processes	1 	2 	M
d. Developmental screenings processes	1 	2 	M
e. Father/partner involvement activities	1 	2 	M
f. Health education activities	1 	2 	M
g. Health insurance outreach and enrollment services	1 	2 	M
h. Home visiting processes	1 	2 	M
i. Linkages to medical home providers	1 	2 	M
j. Linkages to mental and behavioral health services	1 	2 	M
k. Parenting education services	1 	2 	M
l. Reproductive life planning services	1 	2 	M
m. Services that address toxic stress and adverse childhood experiences (ACE)	1 	2 	M
n. Systems and community activities	1 	2 	M
o. Other (specify): ___________________________________	1 	2 	M

6.19 = 1

6.21. What types of outcomes were evaluated? (NHSPS 6.39 modified)

Select one per row.

	Evaluated outcome	Did not evaluate outcome	No Response
Maternal
a. Educational and employment outcomes	1 	2 	M
b. Health behavior and status indicators (pre-pregnancy weight, smoking status, nutrition)	1 	2 	M
c. Interconception outcomes (birth spacing, pregnancy deferment, maternal depression status, pregnancy	1 	2 	M
d. Parental attitudes, knowledge, and parenting behavior	1 	2 	M
e. Use of preventative health services/medical home access	1 	2 	M
f. Use of prenatal care and services	1 	2 	M
Child
g. Birth outcomes and child health status	1 	2 	M
h. Child abuse and neglect	1 	2 	M
i. Child development, achievement, and behavior	1 	2 	M
j. Use of preventative health services/medical home access—immunizations, well-baby checkups	1 	2 	M
Systems
k. Number of referrals completed by provider	1 	2 	M
l. Number of referrals made by provider	1 	2 	M
m. Other (specify): _____________________________________	1 	2 	M

6.19 = 1

6.22. What design method(s) did the evaluation use? (NHSPS 6.37)

Select all that apply

 Comparison group 1

 Cross-sectional descriptive analysis 2

 Longitudinal/time series design 3

 Pre-post design 4

 Trend analysis 4

 Other method not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

6.19 = 1

6.23. For evaluation purposes, were data collected in addition to those required to be reported by the National Healthy Start program? (NHSPS 6.35)

 Yes 1

 No 0

NO RESPONSE M

6.19 = 1

6.24. Does your Healthy Start project have a local evaluator? (NHSPS 6.31)

 Yes 1

 No 0 SKIP TO 6.26

NO RESPONSE M SKIP TO 6.26

6.24 = 1

6.25. Is your local evaluator internal or external?

An internal evaluator is defined as project staff and external as contractors.

(NHSPS 6.32 modified)

 Internal evaluator 1

 External evaluator 2

NO RESPONSE M

6d. HEALTHY START PROJECT ACHIEVEMENTS

ALL

6.26. In Column A, indicate which of the following outcomes your Healthy Start project achieved during [GRANT YEAR].

For the outcomes that your Healthy Start project achieved, specify the benchmark your Healthy Start project used to measure each outcome in Column B (for example, you might enter reduce preterm births as a measure of improved birth outcomes). (NHSPS 6.46 modified)

	COLUMN A		COLUMN B
	Yes	No	IF YES: Benchmark
a. Decreased maternal and infant morbidity	1 	2 
b. Improved birth outcomes	1 	2 
c. Improved child health	1 	2 
d. Improved environment for coordination and integration within and between systems	1 	2 
e. Improved family health	1 	2 
f. Improved maternal health	1 	2 
g. Increased policies to expand coverage, enabling services and infrastructure	1 	2 
h. Reduced unplanned pregnancies	1 	2 

all

6.27 What evidence/findings does your Healthy Start project have to document project achievements? (NHSPS 6.45 modified)

Select all that apply

 Case study findings 1

 Community assessments/data 2

 Local evaluation findings 3

 MCHB performance measures 4

 No short-term/intermediate outcomes were achieved During [GRANT YEAR] 5

 Other evidence or findings not listed above (specify) 99

Specify (STRING 1000)

NO RESPONSE M

all

6.28. Is there anything else you would like to share about your Healthy Start project?

(STRING 1000)

NO RESPONSE M

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