Proposed Updated Appendix_FY 2019_20121.MCH Block Grant Guidance

TITLE V MATERNAL AND
CHILD HEALTH SERVICES
BLOCK GRANT TO STATES
PROGRAM
GUIDANCE AND FORMS
FOR THE
TITLE V APPLICATION/ANNUAL REPORT

APPENDIX OF SUPPORTING DOCUMENTS
U.S. Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health Bureau
Division of State and Community Health
Room 5C-26
5600 Fishers Lane, Rockville, MD 20857
(Phone 301-443-2204 FAX 301-443-9354)

TABLE of CONTENTS
APPENDIX A:

HISTORY AND ADMINISTRATIVE BACKGROUND

3

APPENDIX B:

PERFORMANCE MEASURE FRAMEWORK

7

APPENDIX C:

DETAIL SHEETS FOR THE NATIONAL OUTCOME
MEASURES AND NATIONAL PERFORMANCE MEASURES

25

APPENDIX D:

FAMILY PARTNERSHIP CONTINUUM

82

APPENDIX E:

NEEDS ASSESSMENT − BACKGROUND AND
CONCEPTUAL FRAMEWORK

83

APPENDIX F:

ASSURANCES AND CERTIFICATIONS

88

APPENDIX G:

REQUIRED APPLICATION/ANNUAL REPORT COMPONENTS
AND TIMELINE

91

APPENDIX H:

GLOSSARY

94

2

APPENDIX A: HISTORY AND ADMINISTRATIVE BACKGROUND

As one of the largest Federal block grant programs, Title V is a key source of support for promoting
and improving the health of all the nation’s mothers and children. When Congress passed the Social
Security Act in 1935, it contained the initial key landmark legislation which established Title V. This
legislation is the origin of the federal government’s pledge of support to states and their efforts to
extend and improve health and welfare services for mothers and children throughout the nation. To
date, the Title V federal-state partnership continues to provide a dynamic program to improve the
health of all mothers and children, including children with special health care needs (CSHCN).
A. The Maternal and Child Health Bureau
The Maternal and Child Health Bureau (MCHB) is the principal focus within Health Resources and
Services Administration (HRSA) for all Maternal and Child Health (MCH) activities within the
Department of Health and Human Services (HHS). MCHB’s mission is to improve the health of
America’s mothers, children and families. We envision an America where all children and families
are healthy and thriving. To achieve its mission, MCHB directs resources towards a combination
of integrated public health services and coordinated systems of care for the MCH population.
Within the MCHB, the Division of State and Community Health (DSCH) has the administrative
responsibility for the Title V MCH Services Block Grant to States Program (hereafter referred to as
the MCH Block Grant). DSCH is committed to being the Bureau’s main line of communication with
states and communities, in order to consult and work closely with both of these groups and
others who have an interest in and contribute to the provision of a wide range of MCH programs
and community-based service systems.
B. Maternal and Child Health Services Block Grant (Title V)
Under Title V, MCHB administers a Block Grant and competitive Discretionary Grants. The
purpose of the MCH Block Grant is to create federal/state partnerships in 59 states and
jurisdictions for developing service systems that address MCH challenges, such as:
•
•
•
•
•
•
•
•

Significantly reducing infant mortality;
Providing comprehensive care for all women before, during, and after pregnancy and
childbirth;
Providing preventive and primary care services for infants, children, and adolescents;
Providing comprehensive care for children and adolescents with special health care needs;
Immunizing all children;
Reducing adolescent pregnancy;
Preventing injury and violence;
Putting into community practice national standards and guidelines for prenatal care, for
healthy and safe childcare, and for the health supervision of infants, children, and
adolescents;
3

•
•

Assuring access to care for all mothers and children; and
Meeting the nutritional and developmental needs of mothers, children and families.

Under Title V, MCHB also administers two types of Federal Discretionary Grants, Special Projects
of Regional and National Significance (SPRANS) and Community Integrated Service Systems (CISS)
grants. SPRANS funds projects (through grants, contracts, and other mechanisms) in research,
training, genetic services and newborn screening/follow-up, sickle cell disease, hemophilia, and
MCH improvement. CISS projects (through grants, contracts, and other mechanisms) seek to
increase the capacity for service delivery at the local level and to foster formation of
comprehensive, integrated, community level service systems for mothers and children.
In addition to SPRANS and CISS grants, the MCHB also administers the following categorical
programs:
•
•
•
•
•
•
•
•

Emergency Medical Services for Children;
Sickle Cell Disease Treatment Demonstration Program;
Healthy Start Initiative;
Universal Newborn Hearing Screening;
Heritable Disorder Program
Autism;
Maternal, Infant, and Early Childhood Home Visiting Program; and
Family to Family Health Information Centers

In recent years, some state Title V programs have begun to utilize the life course model as an
organizing framework for addressing identified MCH needs. The life course approach points to
broad social, economic, and environmental factors as underlying contributors to health and social
outcomes. This approach also focuses on persistent inequalities in the health and well-being of
individuals and how the interplay of risk and protective factors at critical points of time can
influence an individual’s health across his/her lifespan and potentially across generations.
C. Maternal and Child Health Block Grant (State Formula Grants)
Since its original authorization in 1935, Title V of the Social Security Act has been amended
several times to reflect the increasing national interest in maternal and child health and wellbeing. One of the first changes occurred when Title V was converted to a block grant program as
part of the Omnibus Budget Reconciliation Act (OBRA) of 1981. This change resulted in the
consolidation of seven categorical programs into a single block grant. These programs included:
•
•
•
•
•

Maternal and Child Health and Services for Children with Special Health Care Needs;
Supplemental Security Income for children with disabilities;
Lead-based paint poisoning prevention programs;
Genetic disease programs;
Sudden infant death syndrome programs;
4

•
•

Hemophilia treatment centers; and
Adolescent pregnancy grants.

Another significant change in the Title V MCH Block Grant came as a result of the Omnibus Budget
Reconciliation Act (OBRA) of 1989, which specified new requirements for accountability. The
amendments enacted under OBRA introduced stricter requirements for the use of federal funds
and for state planning and reporting. Congress sought to balance the flexibility of the block grant
with greater accountability, by requiring State Title V programs to report their progress on key
MCH indicators and other program information. Thus, the block grant legislation emphasizes
accountability while providing states with appropriate flexibility to respond to state-specific MCH
needs and to develop targeted interventions and solutions for addressing them. This theme of
assisting states in the design and implementation of MCH programs to meet state and local
needs, while at the same time asking them to account for the use of federal/state Title V funds,
was embodied in the requirements contained in the Guidance documents for the state MCH Block
Grant Applications/Annual Reports.
In 1993 the Government Performance and Results Act (GPRA), Public Law 103-62, required
federal agencies to establish measurable goals that could be reported as part of the budgetary
process. For the first time, funding decisions were linked directly with performance. Among its
purposes, GPRA is intended to “...improve Federal program effectiveness and public
accountability by promoting a new focus on results, service quality, and customer satisfaction.”
GPRA requires each federal agency to develop comprehensive strategic plans, annual
performance plans with measurable goals and objectives, and annual reports on actual
performance compared to performance goals. The MCHB effort to respond to GPRA
requirements coincided with other planned improvements to the MCH Block Grant Guidance. As
a result, the MCH Block Grant Application/Annual Report and forms contained in the 1997 edition
of the Maternal and Child Health Services Title V Block Grant Program - Guidance and Forms for
the Title V Application/Annual Report served to ensure that the states and jurisdictions could
clearly, concisely, and accurately tell their MCH “stories.” This Application/Annual Report became
the basis by which MCHB met its GPRA reporting requirements for the MCH Block Grant to States
Program.
In 1996, the MCHB began a process of programmatic assessments and planning activities aimed at
improving the Title V MCH Block Grant Application/Annual Report Guidance document for states.
Since that time, the Maternal and Child Health Services Title V Block Grant Program - Guidance
and Forms for the Title V Application/Annual Report (Guidance) has been revised seven times.
Updated Guidance documents are submitted to and approved by the Office of Management and
Budget (OMB) prior to their release. Revisions to each subsequent edition of the Guidance have
considered changes in MCH priorities, availability of new national data sources and opportunities
for refining and streamlining the Application/Annual Report preparation and submission process
for states. The reduced burden that resulted from this latter commitment was largely achieved
through efficiencies that were created by the electronic reporting vehicle for the state MCH Block
Grant Applications/Annual Reports, specifically the Title V Information System (TVIS.)
5

D. Title V Information System
The development of an electronic reporting package in 1996 was a significant milestone for the
State MCH Block Grants. Advances in technology allowed for the development of an electronic
information system (TVIS) within the next several years. The TVIS is designed to capture the
performance data and other program and financial information contained in the state
Applications/Annual Reports. While descriptive information is available on state Title Vsupported efforts, state MCH partnership efforts and other program-specific initiatives of the
state in meeting its MCH needs, TVIS primarily serves as an online, Web-accessible interface for
the submission of the 59 state and jurisdictional Title V MCH Block Grant Applications/Annual
Reports each year by July 15th. Developed in conjunction with the program requirements outlined
in the Title V MCH Block Grant Application/Annual Report Guidance, the TVIS is available to the
public on the World Wide Web at: https://mchdata.hrsa.gov/TVISReports/. Over the years, the
TVIS has increasingly become recognized as a powerful and useful tool for a number of audiences.
The transformational changes to the MCH Block Grant outlined in this revised Application/Annual
Report Guidance mandate the development of a new data collection and web report system for
the TVIS. HRSA is providing funding support for a contract to develop, implement and operate
this new information system.
Integrated with HRSA’s grants management system (i.e., the HRSA Electronic Handbooks (EHB),)
the TVIS makes available to the public through its web reports the key financial, program,
performance, and health indicator data reported by states in their yearly MCH Block Grant
Applications/Annual Reports. Examples of the data that are collected include: information on
populations served; budget and expenditure breakdowns by source of funding, service and
program; program data, such as individuals served and breakdowns of MCH populations; other
state data (OSD); and performance and outcome measure data for the national and state
measures. Reporting on performance relative to the national measures is used to assess national
progress in key MCH priority areas and to facilitate the Bureau’s annual GPRA reporting.

6

APPENDIX B:

Overview of the Framework

PERFORMANCE MEASURE FRAMEWORK

The national performance measure framework is based on a three-tiered performance measure
system: National Outcome Measures (NOMs), National Performance Measures (NPMs), and
Evidence-based or -informed Strategy Measures (ESMs). In brief, NOMs are the ultimate health
outcomes that Title V is attempting to improve. The NPMs are considered to be more directly
modifiable by state Title V program efforts, and influence NOMs. ESMs are developed by states
to capture their evidence-based or informed programmatic efforts to affect NPMs and in turn
NOMs. The framework is intended to better highlight the impact of Title V investments and
provides states with flexibility in selecting NPMs and developing state performance measures
(SPMs) and ESMs to address the state’s priority needs. This guidance reduces the minimum
number of required NPM selections to five; at least one in each population domain. It also
increases flexibility for states to select as many NPMs and SPMs as needed to reflect priority
needs identified from the five-year needs assessment.

Title V Performance Measure Framework

ESMs

NPMs

NOMs

Evidencebased/informed
Strategy Measures

National
Performance
Measures

National
Outcome
Measures

Evaluation Logic Model

Process
Inputs/Outputs

Short, Medium
Term Outcomes

Long Term
Outcomes

Measures were considered as NOMs, which primarily reflect ultimate or longer-term indicators
of population health status or quality systems of care, if they met one or more of the following
criteria: it was mandated by the Title V legislation that the data be collected; it was considered
a sentinel health marker for women, infants, or children; it was a major focus of either the
Title V legislation or Title V activities; it was considered an important health condition to
monitor because the prevalence was increasing, but the reasons for the increase were unclear;
or there was a recognized need to move the MCH field forward in this area, even if there was
not yet a consensus on how to measure the construct. The latter were considered
7

developmental outcome measures. A total of 25 NOMs were selected with three new additions
in the updated guidance: teen births, postpartum depression, and forgone health care.
Measures were considered as NPMs, or short/medium term indicators of health behaviors or
health care access/quality, if they met one or more of the following criteria: there was a large
investment of resources as determined by the state narratives; it was considered modifiable
through Title V activities; a state could delineate measurable activities to address the
performance measures; significant disparities existed among population groups; research had
indicated that the condition or activity had large societal costs; or research had indicated that
the promotion of certain behaviors, practices or policies had improved outcomes. There also
had to be evidence that an NPM was associated with at least one of the NOMs (see Table 2 in
this Appendix) for evidence-based or informed linkages between NPMs and NOMs). However,
it is important to recognize that NOMs are multifactorial and improvement in a given NPM may
not necessarily result in improvement of the associated NOM. Fifteen NPMs were identified for
the Title V MCH Services Block Grant. In this updated guidance, two additional indicators of a
safe sleep environment will be tracked for states that select this NPM.
The ESMs are the key to understanding how a State Title V program tracks programmatic
investments or inputs designed to impact the NPMs. In the framework, states select evidencebased or evidence-informed strategies and activities designed to impact the NPMs; States then
create ESMs to track State Title V strategies and inputs contained in the State Action Plan. The
development of ESMs is guided through an examination of evidenced-based or evidenceinformed strategies, and determining what components are practical, meaningful, measurable,
and achievable. The main criteria for ESMs are being meaningfully related to the selected NPM
through scientific evidence or theory and being measurable by the state with improvement
achievable in multiple years of the five-year reporting cycle. States can determine the number
of ESMs that they will use for addressing the selected NPMs but there is a required minimum of
one ESM for each NPM. States may also add, modify, replace, or retire ESMs over the five-year
reporting cycle, as new strategies or measurement methods emerge, objectives are achieved
without further room for improvement, or the strategy did not produce intended results.
The 15 NPMs address key national MCH priority areas in five MCH population health domains:
1) Women/Maternal Health; 2) Perinatal/Infant Health; 3) Child Health; 4) CSHCN; and
5) Adolescent Health. The five MCH population health domains are contained within the three
legislatively-defined MCH populations [Section 505(a)(1).] The first two domains are included
under “preventive and primary care services for pregnant women, mothers and infants up to
age one,” which is the first of the three defined MCH populations. Child and adolescent health
are included in the second defined MCH population, specifically “preventive and primary care
services for children.” Services for CSHCN is the third legislatively-defined MCH population.
Presented in the table below are the 15 NPMs and the corresponding MCH Population
domain(s) and applicable subgroup options for ESMs.

8

Table 1. NPMs and MCH Population Domains
NPM
#
1
2
3

National Performance
Measures

MCH Population Domains
Women/Maternal Health
Women/Maternal Health
Perinatal/Infant Health

4
5
6
7

Well-woman visit
Low-risk cesarean delivery
Risk-appropriate perinatal
care
Breastfeeding
Safe sleep
Developmental screening
Injury hospitalization

8

Physical activity

Child Health and/or
Adolescent Health

9
10
11

Bullying
Adolescent well-visit
Medical home

12

Transition

13

Preventive dental visit –
Pregnancy
Preventive dental visit –
Child/Adolescent

Adolescent Health
Adolescent Health
Children with Special Health
Care Needs (CSHCN), Child
and Adolescent Health
Children with Special Health
Care Needs (CSHCN) and
Adolescent Health
Women/Maternal Health, Child
Health, and/or Adolescent
Health

14

Smoking – Pregnancy
Smoking – Household

Women/Maternal Health, Child
Health, and/or Adolescent
Health

15

Adequate insurance

Child Health, Adolescent
Health, and/or Children with
Special Health Care Needs
(CSHCN)

Perinatal/Infant Health
Perinatal/Infant Health
Child Health
Child Health and/or
Adolescent Health

ESM Subgroup Options
(if applicable)

Children 0 through 9
Adolescents 10 through 19
All Children 0 through 19
Children 6 through 11
Adolescents 12 through 17
All Children 6 through 17

CSHCN
CSHCN and non-CSHCN
CSHCN
CSHCN and non-CSHCN
Pregnant women
Children 0 through 5
Children 6 through 11
Adolescents 12 through 17
All Children 0 through 17
Pregnant women
Children 0 through 5
Children 6 through 11
Adolescents 12 through 17
All Children 0 through 17
All Children
CSHCN

The NPMs incorporate two significant concepts: first, Title V is responsible for promoting the
health of all mothers and children, which includes an emphasis on CSHCN and their families;
and second, the development of life course theory has indicated that there are critical stages,
beginning before a child is born and continuing throughout life, which can influence lifelong
health and wellbeing (see Table 3 in this Appendix for a crosswalk of NPM/NOMs and AMCHP
Lifecourse Indicators).
In implementing this framework, states will choose a minimum five out of 15 NPMs for its
Title V program to address during the current five-year needs assessment cycle, at least one in
each MCH population domain. To promote flexibility, each MCH population domain contains at
least three NPM options. The same measure selected in multiple domains (NPM #7, NPM #8,
9

NPM #11, NPM #12, NPM #13, NPM #14 and NPM #15) will only count once toward the
minimum of five. There are no mandatory NPMs and no maximum for the number of NPMs
that a state can select. Thus, a state is not required to make any changes to its current NPM
selections and the state may continue to implement the State Action Plan that was established
for the current reporting cycle.
For example, if a state selects a compound measure such as NPM #14 in Women/Maternal
Health and Child Health, it would only count once towards the minimum of five NPMs, and
another measure would need to be selected in either Women/Maternal or Child Health to
satisfy the requirement of one measure in each population domain. Injury hospitalization,
physical activity, medical home, preventive dental visit, household smoking, and adequate
insurance can be selected for either the Child or the Adolescent Health domains, or both,
because the age ranges span both domains. It is recognized that the strategies and
accompanying ESMs may be different, depending on the children’s ages, for injury
hospitalization, physical activity, preventive dental visit, and household smoking; therefore,
these measures have various subgroup options for specifying the focus of ESMs. Given their
particular importance for CSHCN, medical home and transition must include a focus on CSHCN,
even if they are selected within the Child and/or Adolescent Health domain.
When selecting NPMs it is important that the alignment of the NPMs to the state identified
priorities is clear. If the priority does not align with a NPM, the state should develop a state
performance measure (SPM). The minimum of five NPMs allows states flexibility, and ensures
that the selected NPMs and chosen SPMs together reflect the state’s identified priority needs.
While the SPM is not part of the national performance measurement framework, it is a critical
component in addressing priorities. States can select as many SPMs as they need to address
their MCH priority needs.
A sixth domain, Cross-Cutting/Systems Building, refers to public health system issues that
impact all MCH population groups. This domain does not contain any NPMs but allows states
to develop unique SPMs to address priority areas that cut across all population health domains.
Example SPM topics may include but are not limited to:
•
•
•
•

Family partnership activities across all population health domains;
Social determinants of health;
Workforce development; and
Enhancement of data infrastructure.

Implementation of Measurement
National Outcome Measures
NOMs are longer-term and/or legislatively required indicators, many of which may be
influenced by NPMs (see Table 2) and are important to monitor and assess as a core function of
public health that may stimulate program and policy action. Thus, NOMs should be tracked to
10

understand the MCH population’s health, and are important for the development of the needs
assessment and selection of NPMs. Changes in NOM indicators, which may result from
improvement in NPMs, can be discussed in the appropriate population domain section of the
narrative, but there is not a reporting requirement for this discussion. Data for NOMs will be
prepopulated, where possible. States do not provide performance objectives for NOMs.
National Performance Measures
Once NPMs are selected, a state will track the five NPMs throughout the five-year reporting
cycle. States are encouraged not to change the selected NPMs during the five-year reporting
cycle. If a state determines that a NPM needs to be changed, clear justification must be
provided. In an effort to reduce state burden, annual performance data (indicator/numerator/
denominator) for the NOMs and the NPMs will be prepopulated by MCHB from national data
sources, as available, and provided to the states for their use in preparing the yearly Title V
MCH Block Grant Applications/Annual Reports. Data will be provided overall by year to
facilitate objective-setting and performance monitoring, as well as by various demographic
stratifiers (e.g. age, race/ethnicity, education, urban/rural residence) to identify priority
populations for targeting strategies and programmatic interventions. If a state selects a NPM
which is not part of the national data source, the state can develop its own detail sheet and
report its data for the measure. However, the definition and data that are collected must
match the definition and measure of the national data source.
In the first reporting year of this Guidance, a state will select a minimum of five NPMs to
complete the current five-year needs assessment cycle ending in FY 2020. States will continue
using the determined performance objectives from the previous guidance until FY 2020.
Performance objectives for future years can be changed for individual NPMs based on ongoing
needs assessment efforts and performance monitoring.
Other Guidelines for NPMs
Use of Provisional Data: States may, but are not required to, include more timely provisional
data if they choose. Providing this data will not replace the prepopulated final data provided
for the measures.
Lacking a National Data Source: States can choose a measure if they do not have the data
source noted on the detail sheet, as long as they provide the indicator, numerator and
denominator data as defined on the detail sheet. For Pregnancy Risk Assessment Monitoring
System (PRAMS), states will be able to submit their PRAMS or PRAMS-like data to TVIS
following the same definition for a given measure if CDC cannot furnish it. The same situation
may apply to other data sources; for example, not all states with hospital discharge data furnish
it to AHRQ. If a state provides its own data from a different source, this should be annotated in
a field note.

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Integrated Measures (NPM #13 and NPM #14): The integrated measures of preventive dental
visit and smoking have two distinct measures, one in pregnancy and one for
children/adolescents. States may select these NPMs for one or more of the following MCH
population domains: Women/Maternal Health; Child Health; Adolescent Health. If a state
selects one of these NPMs for Women/Maternal Health (#13.1 and NPM #14.1) and also for
Child and/or Adolescent Health (NPM #13.1 and NPM #14.1), states will be expected to develop
multiple ESMs, at least one for each measure.
Evidence-based or -informed Strategy Measures
Developed by the state, ESMs are measures that quantify and assess the outputs of State
Title V strategies and inputs identified in the State Action Plan. The development of ESMs is
guided through an examination of evidenced-based or evidence-informed strategies, and
determining which components are meaningful, measurable, and achievable. The main criteria
for ESMs is that they are meaningfully related to the selected NPM through scientific evidence
or theory, and they are measurable by the state with improvement achievable in multiple years
or throughout the five-year reporting cycle. Most issues in MCH are multifactorial; therefore,
states are strongly encouraged to develop multiple strategies, each with a related ESM, to
impact a selected NPM. Given that ESMs capture state programmatic efforts, it is
recommended that states develop corresponding ESMs for strategies in which they are
investing the most activity and/or funding. However, states are only required to have at least
one active ESM for each of the NPMs selected.
The key for selecting an effective strategy to impact an NPM is identifying evidence-based or –
informed practices. Since the initiation of the MCH Block Grant transformation in 2015, MCHB
has supported a variety of technical assistance efforts to support States in the identification and
implementation of evidence-based or -informed MCH program strategies and measures. For
example, MCHB funded the Strengthen the Evidence Base for MCH Programs initiative at The
Johns Hopkins University (http://semch.org/about.html). This partnership initiative promotes
an “evidence-informed” approach, which the McMaster group defines as “the purposeful and
systematic use of the best available evidence to inform the assessment of various options and
related decision making in practice, program development, and policy making.” 1 Consistent
with this approach, the initiative has developed a continuum of evidence model that helps
states to use the best available MCH science while also encouraging innovation in evidenceinformed programming (http://www.semch.org/rating-the-evidence.html). Evidence-based
strategies are generally those that have either moderate evidence or are scientifically rigorous,
while evidence-informed are those that have emerging evidence or are based on expert
opinion. “Evidence-informed” is meant to convey that there is information suggesting that a
certain strategy could be effective in addressing a NPM. These are strategies that have not yet

1

McMaster University. Health Evidence Glossary. Available
http://www.healthevidence.org/glossary.aspx#E, Accessed 9/9/15

12

been rigorously tested or evaluated but that incorporate a theoretical model from other
effective public health practices or apply a novel approach grounded in scientific theory.
This continuum and its rationale is shown in the following figure.
The Evidence Continuum
Expert
Opinion

Mixed
Evidence
Evidence
Against

Scientifically
Rigorous
Emerging
Evidence

Moderate
Evidence

For each category of evidence noted above, the table below provides a descriptive statement
and criteria.
Evidence Ratings (Adapted from RWJ What Works for Health) 2
Rating

Explanation

Scientifically Rigorous

Strategies with this rating are most likely to make a difference. These strategies have
been tested in many robust studies with consistently positive results.
Strategies with this rating are likely to work, but further research is needed to confirm
effects. These strategies have been tested more than once and results trend positive
overall.

Moderate Evidence

Expert Opinion

Emerging Evidence
Mixed Evidence
Evidence Against

Strategies with this rating are recommended by credible, impartial experts and are
consistent with accepted theoretical frameworks. However, the strategies have limited
research documenting effects; further research, often with stronger designs, is needed
to confirm effects.
Strategies with this rating have limited research documenting effects. These strategies
need further research, often with stronger designs, to confirm effects.
Strategies with this rating have been tested more than once and results are
inconsistent or trend negative; further research is needed to confirm effects.
Strategies with this rating are not good investments. These strategies have been
tested in many robust studies, are not effective and sometimes produce harmful
results.

Beyond scientific evidence of effectiveness, additional considerations of reach, feasibility,
sustainability, and transferability should be considered in terms of likely impact. It is important
to note that there may be a need for states to adapt strategies based on differences in
populations and settings, available resources and other considerations.
2

Adapted from the Robert Wood Johnson What Works for Health project. Available at:
http://www.countyhealthrankings.org/roadmaps/what-works-for-health, accessed 9/9/15

13

The checklist below may be helpful in identifying a meaningful strategy and operationalizing the
output as a measure. A given strategy should be based on, or informed by, evidence of
effective practice in direct relation to improving the NPM rather than a strategy that has an
indirect relationship. An example of an indirect relation are efforts to improve the content or
quality of well-woman or adolescent visits as a strategy for improving access or utilization.
While the ESMs may be either directly or indirectly related to the NPM, states/jurisdictions are
encouraged to select at least one ESM that directly corresponds to the selected NPM. The
strategy should be relevant to state priorities and tailored or adapted for contextual settings
and population groups where applicable. It is similarly critical for the strategy to be feasible for
the state to implement within the five-year cycle and involve stakeholder input or buy-in from
partners who may be instrumental in successfully executing the strategy or tracking output.
The strategy should also have potential for improvement (i.e. not already or nearly
accomplished).
ESM Checklist
1: The strategy is meaningful
The strategy is evidence-based/informed in direct relation to the NPM
The strategy is relevant to state priorities and context
The strategy is feasible and involved stakeholder input or buy-in
The strategy has potential for improvement
2: The strategy output is measurable as an ESM
The ESM is a number, %, rate, count, yes/no*
The ESM is well-defined and specific
Data are available to measure and track the ESM over time
The ESM can show incremental change over time
3: Improvement in the ESM is achievable
Improvement attainable over multiple assessments
Sensitive to change within a defined time period

Check if Answer is
Yes

□
□
□
□
□
□
□
□
□
□

*Quantitative measures are recommended over qualitative yes/no measures to quantify strategy outputs and
show improvement over time in relation to the NPM.

Once the state identifies a strategy it intends to use, the state will develop and operationalize
the outputs of this strategy as a measure or ESM. Given that ESMs are intended to measure
progress over time, they should be quantifiable (e.g., number, percent, rate, count),
well-defined and specific (i.e., specifically defined indicator, numerator, and denominator), and
there should be data available to measure and track the ESM with incremental change over
time. The setting of improvement objectives marks the final phase of ESM development and
offers an important check that improvement in the ESM is expected and attainable over
multiple assessments within a reasonable time period. Objectives should reflect an
improvement goal over multiple years of the five-year reporting cycle rather than a static
14

objective over time. Sample strategies, measures, and objectives for NPM #5 are provided
within the publication by Kogan et al (2015). 3
While yes/no measures are acceptable, quantitative measures are preferred to capture greater
detail on strategy outputs and show more than a single improvement over time. A yes/no
indicator tends to either capture a single activity toward a broader strategy that is achieved in
one year and lacks future opportunity for improvement over multiple assessments or a very
broad policy change that may not show progress for many years. In both cases, multi-year
improvement in the ESM is not attainable due to a yes/no specification. Ideally, there should
be annual and incremental improvements shown over time in an ESM that can be examined in
relation to changes in the corresponding NPM.
For example, a state may select an evidence-informed strategy of improving provider training
on a particular topic. This could be broken down into smaller activities, such as identifying or
developing a training curriculum and then administering or promoting the training, but these
activities are part of a broader strategy that could be tracked consistently over time with an
indicator of the number or percentage of providers who received training. Activities may be
discussed in the narrative section to provide context to any ESM. To further strengthen
incremental improvement potential, the ESM could reference the receipt of training within the
past 3 to 5 years since the number trained in a given year may not increase over time and lack
an appropriate improvement objective.
Another example involves a strategy of implementing a policy or program. Similar to the
example above, a yes/no measure lacks potential to show improvement over multiple
assessments and, in this case, progress may or may not be achievable in a reasonable period.
When a yes/no option is being considered, it is best to identify and track fidelity to the
policy/program goal through a quantitative measure with potential for incremental
improvement through additional activities or to assure intended results after implementation.
For example, a strategy for a policy change to increase Medicaid eligibility may not be
achievable for many years but the goal of the strategy to improve Medicaid enrollment (#/%
enrolled) could be directly assessed and show progress over multiple years through additional
activities, such as outreach and enrollment, both before and after a Medicaid policy or
procedural change.
States have provided strong examples of well-defined and well-written ESMs, which
demonstrate that states have examined the evidence-base for a strategy, determined the
appropriate way to measure the strategy, and developed improvement objectives.
For the annual reports covered under this Guidance, as new ESMs are introduced, states will
develop a detail sheet for each ESM, which they will submit as part of their Application/Annual
3

: Kogan MD, Dykton C, Hirai AH, Strickland BB, Bethell CD, Naqvi I, Cano CE, Downing-Futrell SL, Lu MC. A
new performance measurement system for maternal and child health in the United States. Matern Child Health J.
2015 May;19(5):945-57. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428536

15

Report. On the detail sheet, states will define the: (1) measures; (2) goal; (3) indicator,
numerator, and denominator; (4) data source; and (5) significance. States will track
performance for the ESMs that were established for this five-year needs assessment cycle.
States will determine performance objectives for each of the ESMs for application years
FY 2019 - FY 2020. These objectives can be revised, as needed, for future reporting years. Data
for the ESMs (i.e., numerator/denominator) will be entered annually by the state. During the
five-year reporting cycle, ESMs may be added, modified, replaced, or retired, as new strategies
or measurement methods emerge, objectives are achieved without further room for
improvement, or the strategy did not produce intended results.
States should work closely with family partnerships as they revise/develop the ESMs for their
selected NPMs. For purposes of the MCH Block Grant, family partnership is defined as patients,
families, their representatives, and health professionals working in active partnership at various
levels across the health care system - direct care, organizational design, governance and policy
making - to improve health and health care. This partnership is accomplished through the
intentional practice of working with families for the ultimate goal of positive outcomes in all
areas through the life course. 4 Relevant resources include, but are not limited to, the National
Consensus Standards for Systems of Care for Children and Youth with Special Health Care Needs,
authored by the Association of Maternal and Child Health Programs (AMCHP, 2014) and
available at:
http://www.lpfch.org/sites/default/files/field/publications/developing_structure_and_process
_-_white_paper_and_standards.pdf; a series of reports and case studies entitled, Sustaining
and Diversifying Family Engagement in Title V MCH and CYSHCN Programs (AMCHP, 2016); and
other resources that are available through Family Voices.
Working with the Measures States Currently Have
As noted, this Guidance reduces the minimum number of required NPM selections to five, with
at least one in each population domain. States have the option to continue using measures
selected in the previous guidance, provided the NPMs selected in multiple domains (NPM #7,
NPM #8, NPM #11, NPM #12, NPM #13, NPM #14 and NPM #15) only count once toward the
minimum of five. With a reduced number of NPMs, states have increased flexibility and may
choose to retire up to three NPMs (out of the eight selected NPMs) from the previous Guidance
to better address the state’s priorities. If retiring measures, the state should provide reasoning
in their FY 2019 application for the retired measure.
Selecting New Measures
The reduced number of NPMs allows states more flexibility in developing SPMs that align with
the state’s priorities. States also have the opportunity to develop SPMs that will specifically
4

Carman K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtcl, C., Sweeney, J. “Patient and Family
Engagement: A framework for understanding the elements and developing interventions and policies.” Health
Affairs. 2013; 32:223-231.

16

impact infrastructure through the Cross-cutting/Systems Building domain to improve the areas
impacting multiple population domains like family partnership and data infrastructure.
When selecting new measures it is important that the following checklist items have been
satisfied.

Measure Checklist

Check if Answer
is Yes

A minimum of 5 NPMs is selected
There is at least one NPM selected for each population health domain
*NPM #7, #8, #11, #12, #13, #14, #15 selected in multiple domains count
once toward the minimum of five
There is a NPM/SPM for each state priority
All selected NPMs/SPMs have clear alignment with the state priorities

□
□
□
□

State Performance and Outcome Measures
To address state priorities not addressed by the National Performance Measures, the State
Performance Measures (SPMs) can be developed. There is no minimum or maximum number
of SPMs required. As mentioned earlier, the combination of NPMs with state-developed SPMs
allows the state flexibility to reflect its priority needs from the most recent Five-Year Needs
Assessment. For the developed SPMs, states will continue with the performance objectives for
five years (FY 2018-FY 2022) for each of the measures. States may revise their SPM objectives
in future years’ Applications/Annual Reports. The development of the SPMs coincides with the
selection of NPMs and the development of the state ESMs.
States will also develop detail sheets on these measures, which will define the: (1) measure;
(2) goal; (3) indicator, numerator, and denominator; (4) data source; and (5) significance.
States will track their developed SPMs throughout the five-year reporting cycle. Data for the
SPMs (i.e., indicator/numerator/denominator) will be entered annually by the state. A state
can retire a SPM during the five-year reporting cycle and replace it with another SPM based on
its MCH priority needs. States are not required to develop ESMs for SPMs.
A state may also develop (but is not required to develop) one or more State Outcome Measures
(SOMs) based on its MCH priorities, as determined by the findings of the Five-Year Needs
Assessment, provided that none of the NOMs address the same priority area for the state. A
SOM should be linked with a performance measure to show the impact of performance on the
intended outcome. States will track the SOMs during the five-year reporting cycle and the SOM
can be retired if the state chooses. Data for the SOMs (i.e., indicator/numerator/ denominator)
will be entered annually by the state.

17

1
2
3
4
5
6
7
8
9.1
9.2
9.3
9.4
9.5
10
11
12
13
14
15
16.1
16.2
16.3
17.1
17.2
17.3
17.4
18
19
20
21
22.1
22.2
22.3
22.4
22.5
23
24
25

Early prenatal care
Severe maternal
morbidity
Maternal mortality
Low birth weight
Preterm birth
Early term birth
Early elective delivery
Perinatal mortality
Infant mortality
Neonatal mortality
Postneonatal mortality
Preterm-related
mortality
SUID mortality
Drinking during
pregnancy
Neonatal abstinence
syndrome
Newborn screening
timely follow-up
School readiness
Tooth decay/cavities
Child mortality
Adolescent mortality
Adolescent motor
vehicle death
Adolescent suicide
CSHCN
CSHCN systems of care
Autism
ADD/ADHD
Mental health treatment
Overall health status
Obesity
Uninsured
Child vaccination
Flu vaccination
HPV vaccination
Tdap vaccination
Meningitis vaccination
Teen births
Postpartum depression
Forgone health care

Breastfeeding

Safe sleep

12

13

14

15

Adequate
insurance

5

Smoking

4

Preventive dental
visit

3
Risk-appropriate
perinatal care

x
x
x
x

x
x
x
x
x

x
x
x

x

x

x

x

x

x

Medical home

x

Adolescent
well-visit

x
x
x
x

Bullying

x

Physical activity

x

Injury
hospitalization

x

Developmental
screening

Short Title

2
Low-risk cesarean
delivery

#

National Performance Measure
6
7
8
9
10
11

1
Well-woman visit

National Outcome Measure

Transition

Table 2. Evidence-based/informed National Performance and Outcome Measure Linkages*

x
x
x
x
x

x

x

x
x

x
x
x
x
x

x

x
x

x

x

x
x

x

x
x

x
x
x

x
x

x

x

x

x

x
x
x
x
x

x
x
x
x
x

x
x

x

* Includes linkages based on expert opinion or theory in the absence of empirical scientific evidence. Associations with
available empirical scientific evidence that is mixed or inconclusive are not included. This table is subject to revision as
new scientific evidence becomes available. By definition, NPMs must be linked to at least one NOM; however, not all
NOMs must have linked NPMs, as they may be important to monitor as sentinel health indicators regardless.

18

x
x

x

References for Table 2
NPM-1 Well-Woman Visit
American Congress of Obstetricians and Gynecologists (ACOG). Well-Woman
Recommendations. http://www.acog.org/wellwoman
Centers for Disease Control and Prevention (CDC). Preconception Health and Health Care.
https://www.cdc.gov/preconception/careforwomen
NPM-2 Low-Risk Cesarean Delivery
Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.
http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/SafePrevention-of-the-Primary-Cesarean-Delivery
NPM-3 Risk-Appropriate Perinatal Care
American Academy of Pediatrics Committee on Fetus And Newborn. Levels of neonatal care.
Pediatrics. 2012 Sep;130(3):587-97. http://pediatrics.aappublications.org/content/130/3/587
NPM-4 Breastfeeding
Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N,
Rollins NC; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology,
mechanisms, and lifelong effect. Lancet. 2016 Jan 30;387(10017):475-90.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human
milk. Pediatrics. 2012 Mar;129(3):e827-41.
http://pediatrics.aappublications.org/content/early/2012/02/22/peds.2011-3552
Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst
Rev. 2012 Aug 15;(8):CD003517.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003517.pub2/full
NPM-5 Safe Sleep
Taskforce on Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths:
Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2016
Nov;138(5). http://pediatrics.aappublications.org/content/138/5/e20162938

19

Taskforce on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths:
expansion of recommendations for a safe sleeping environment. Pediatrics. 2011; 128(5)
e1341-e1367. http://pediatrics.aappublications.org/content/128/5/1030
NPM-6 Developmental Screening
Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright
Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project
Advisory Committee. Identifying infants and young children with developmental disorders in
the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006
Jul;118(1):405-20. http://pediatrics.aappublications.org/content/118/1/405
Hagan, JF, Shaw JS, Duncan PM. Bright Futures: guidelines for health supervision of infants,
children and adolescents. Fourth Edition. Elk Grove Village, IL: American Academy of Pediatrics.
2017.
NPM-7 Injury Hospitalization
Centers for Disease Control and Prevention (CDC). VitalSigns: Child Injury. April 2012.
https://www.cdc.gov/vitalsigns/childinjury/
Centers for Disease Control and Prevention (CDC). Suicide: Facts at a Glance.
https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
Centers for Disease Control and Prevention (CDC). Youth Violence: Facts at a Glance.
https://www.cdc.gov/violenceprevention/pdf/yv-datasheet.pdf
NPM-8 Physical Activity
U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans
https://health.gov/paguidelines/guidelines/
NPM-9 Bullying
Holt MK, Vivolo-Kantor AM, Polanin JR, Holland KM, DeGue S, Matjasko JL, Wolfe M, Reid G.
Bullying and suicidal ideation and behaviors: a meta-analysis. Pediatrics. 2015 Feb;135(2):e496509. http://pediatrics.aappublications.org/content/135/2/e496
NPM-10 Adolescent Well-Visit
National Adolescent and Young Adult Health Information Center (2016). Summary of
Recommended Guidelines for Clinical Preventive Services for Adolescents up to age 18. San
Francisco, CA: National Adolescent and Young Adult Health Information Center, University of
California, San Francisco. Retrieved from http://nahic.ucsf.edu/adolescent-guidelines
20

NPM-11 Medical Home
Hadland SE, Long WE. A systematic review of the medical home for children without special
health care needs. Matern Child Health J. 2014 May;18(4):891-8.
https://link.springer.com/article/10.1007/s10995-013-1315-9
Homer CJ, Klatka K, Romm D, Kuhlthau K, Bloom S, Newacheck P, Van Cleave J, Perrin JM. A
review of the evidence for the medical home for children with special health care needs.
Pediatrics. 2008 Oct;122(4):e922-37. http://pediatrics.aappublications.org/content/122/4/e922
MCHB-funded National Resource Center: National Center for Medical Home Implementation,
https://medicalhomeinfo.aap.org/Pages/default.aspx
NPM-12 Transition
American Academy of Pediatrics, American Academy of Family Physicians, and American
College of Physicians, Transitions Clinical Report Authoring Group. Clinical Report – Supporting
the Health Care Transition from Adolescence to Adulthood in the Medical Home. Pediatrics.
2011: 128; 182-2000.
American Academy of Pediatrics; American Academy of Family Physicians; American College of
Physicians-American Society of Internal Medicine. A consensus statement on health care
transitions for young adults with special health care needs. Pediatrics. 2002 Dec;110(6 Pt
2):1304-6. http://pediatrics.aappublications.org/content/110/Supplement_3/1304
Campbell F, Biggs K, Aldiss SK, O'Neill PM, Clowes M, McDonagh J, While A, Gibson F. Transition
of care for adolescents from paediatric services to adult health services. Cochrane Database
Syst Rev. 2016 Apr 29;4:CD009794.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009794.pub2/abstract
NPM-13 Preventive Dental Visit
American Academy of Pediatric Dentistry. Guideline on Perinatal and Infant Oral Health Care.
Pediatr Dent. 2016 Oct;38(6):150-154.
http://www.aapd.org/media/Policies_Guidelines/G_PerinatalOralHealthCare3.pdf
American College of Obstetricians and Gynecologists Women's Health Care Physicians;
Committee on Health Care for Underserved Women. Committee Opinion No. 569: oral health
care during pregnancy and through the lifespan. Obstet Gynecol. 2013 Aug;122(2 Pt 1):417-22.
http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-HealthCare-for-Underserved-Women/Oral-Health-Care-During-Pregnancy-and-Through-the-Lifespan

21

American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive
dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and
adolescents. Pediatr Dent. 2013 Sep-Oct;35(5):E148-56.
http://www.aapd.org/media/Policies_Guidelines/G_Periodicity7.pdf
NPM-14 Smoking
The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General.
Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office
on Smoking and Health, 2014. https://www.surgeongeneral.gov/library/reports/50-years-ofprogress/index.html
U.S. Department of Health and Human Services. The Health Consequences of Involuntary
Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center
for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health, 2006. https://www.ncbi.nlm.nih.gov/books/NBK44324/
NPM-15 Adequate Insurance
Kogan MD, Newacheck PW, Blumberg SJ, Ghandour RM, Singh GK, Strickland BB, van Dyck PC.
Underinsurance among children in the United States. N Engl J Med. 2010Aug 26;363(9):841-51.
http://www.nejm.org/doi/full/10.1056/NEJMsa0909994
Smith PJ, Molinari NA, Rodewald LE. Underinsurance and pediatric immunization delivery in the
United States. Pediatrics. 2009 Dec;124 Suppl 5:S507-14.
http://pediatrics.aappublications.org/content/124/Supplement_5/S507.full
Smith PJ, Lindley MC, Shefer A, Rodewald LE. Underinsurance and adolescent immunization
delivery in the United States. Pediatrics. 2009 Dec;124 Suppl 5:S515-21.
http://pediatrics.aappublications.org/content/124/Supplement_5/S515.full
IOM (Institute of Medicine). 2009. America’s Uninsured Crisis: Consequences for Health and
Health Care. Washington, DC: National Academies Press.
http://www.nationalacademies.org/hmd/Reports/2009/Americas-Uninsured-CrisisConsequences-for-Health-and-Health-Care.aspx

22

Table 3. National Performance and Outcome Measure Crosswalk to AMCHP Life Course Indicators
National Performance or
Outcome Measure
#
Short Title

Identifier

4B

Breastfeeding

LC-27*

Family Wellbeing

6

Developmental
screening

LC-19**

Early Life Services

8.2

Physical activity

LC-33 *

Family Wellbeing

Physical Activity
Among High School
Students

9.1

Bullying

LC-12

Discrimination and
Segregation

Bullying

11

Medical home

LC-37

Health Care Access
and Quality

Medical Home for
Children

13.2

Preventive dental
visit

LC-41

Health Care Access
and Quality

14.2

Smoking

LC-28

5

Preterm birth

LC-55

12

Newborn screening
timely follow-up

LC-17**

Oral Health
Preventive Visit for
Children
Family Wellbeing
Exposure to Second
Hand Smoke in the
Home
National Outcome Measure
Reproductive Life
Preterm Birth
Experiences
Early Life Services
Early Intervention

16.3

Adolescent suicide

LC-45*

Mental Health

Suicide

17.1

CSHCN

LC-25

Family Wellbeing

20.2

Obesity

LC-32A

Family Wellbeing

Children with
Special Health Care
Needs
Obesity

22.1

Child vaccination

LC-35

Health Care Access
and Quality

Children Receiving
Age Appropriate
Immunizations

22.3

HPV vaccination

LC-36A*

Health Care Access
and Quality

Human
Papillomavirus
(HPV) Immunization

AMCHP Life Course Indicators
Thematic Category

Indicator Name

Brief Description

National Performance Measure

23

Exclusive
Breastfeeding at 3
Months
Early Childhood
Health Screening EPSDT

Percent of children
exclusively breastfed
through 3 months
Percent of Medicaid-enrolled
children who received at
least one initial or periodic
screen in past calendar year
Proportion of high school
students who are physically
active for at least 60 minutes
per day on five or more of
the past seven days.
Percent of 9-12th graders
who reported being bullied
on school property or
electronically bullied
Proportion of families who
report their child received
services in a medical home
Percent of children who
received a preventive dental
visit in the past 12 months
Percent of children living in a
household where smoking
occurs inside home
Percent of live births born <
37 weeks gestation
Proportion of children aged
0-3 years who received EI
services of all children aged
0-3 years
Suicides per 100,000
population
Percent of children (0-17
years) with a special health
care need
Percent of children who are
currently overweight or
obese
Percent of children ages 1935 receiving age-appropriate
immunizations according to
the Advisory Committee for
Immunization Practices
(ACIP) guidelines and HP
2020 Goal.
The proportion of
adolescents ages 13-17 who
receive the evidence-based
clinical preventive service
HPV vaccine

Table 3. National Performance and Outcome Measure Crosswalk to AMCHP Life Course Indicators
(Continued)
National Performance or
Outcome Measure
#
Short Title

AMCHP Life Course Indicators
Identifier

Thematic Category

Indicator Name

Brief Description

National Outcome Measure
23

Teen births

LC-54*

Reproductive Life
Experiences

Teen Births

Number of live births born to
women aged 10-19 years
per 1,000 women aged 1019 years

24

Postpartum
depression

LC-44

Mental Health

Postpartum
Depression

25

Forgone health
care

LC-39*

Health Care Access
and Quality

Inability or Delay in
Obtaining Necessary
Medical Care or
Dental Care

Percent of women who have
recently given birth who
reported experiencing
postpartum depression
following a live birth
Percent of parents reporting
their child was not able to
obtain necessary medical
care or dental care.

*NPM or NOM similar to AMCHP indicator (different age range or definition)
**NPM or NOM conceptually related to AMCHP indicator
Source: http://www.amchp.org/programsandtopics/data-assessment/Pages/LifeCourseIndicators.aspx

24

APPENDIX C:

DETAIL SHEETS FOR THE NATIONAL OUTCOME
MEASURES AND NATIONAL PERFORMANCE
MEASURES

A.

National Outcome Measures

B.

National Performance Measures

25

A.

No. Title V MCH Services Block Grant - National Outcome Measures
1
2
3
4
5
6
7
8
9.1
9.2
9.3
9.4
9.5
10
11
12

Percent of pregnant women who receive prenatal care beginning in the first trimester
Rate of severe maternal morbidity per 10,000 delivery hospitalizations
Maternal mortality rate per 100,000 live births
Percent of low birth weight deliveries (<2,500 grams)
Percent of preterm births (<37 weeks gestation)
Percent of early term births (37,38 weeks gestation)
Percent of non-medically indicated early elective deliveries
Perinatal mortality rate per 1,000 live births plus fetal deaths
Infant mortality rate per 1,000 live births
Neonatal mortality rate per 1,000 live births
Postneonatal mortality rate per 1,000 live births
Preterm-related mortality rate per 100,000 live births
Sleep-related Sudden Unexpected Infant Death (SUID) rate per 100,000 live births
Percent of infants born with fetal alcohol exposure in the last 3 months of pregnancy
The rate of infants born with neonatal abstinence syndrome per 1,000 hospital births
Percent of eligible newborns screened for heritable disorders with on time physician notification for out of
range screens who are followed up in a timely manner. (DEVELOPMENTAL)

13
14

Percent of children meeting the criteria developed for school readiness (DEVELOPMENTAL)
Percent of children, ages 1 through 17, who have decayed teeth or cavities in the past year

15
16.1
16.2
16.3
17.1
17.2

Child mortality rate, ages 1 through 9, per 100,000
Adolescent mortality rate, ages 10 through 19, per 100,000
Adolescent motor vehicle mortality rate ages 15 through 19 per 100,000
Adolescent suicide rate ages 15 through 19 per 100,000
Percent of children with special health care needs (CSHCN), ages 0 through 17
Percent of children with special health care needs (CSHCN), ages 0 through 17, who receive care in a
well-functioning system

17.3
17.4

Percent of children, ages 3 through 17, diagnosed with an autism spectrum disorder
Percent of children, ages 3 through 17, diagnosed with Attention Deficit Disorder/Attention Deficit
Hyperactivity Disorder (ADD/ADHD)

18

Percent of children, ages 3 through 17, with a mental/behavioral condition who receive treatment or
counseling
Percent of children, ages 0 through 17, in excellent or very good health
Percent of children, ages 2 through 4, and adolescents, ages 10 through 17, who are obese (BMI at or
above the 95th percentile)
Percent of children, ages 0 through 17, without health insurance
Percent of children, ages 19 through 35 months, who have completed the combined 7-vaccine series
(4:3:1:3*:3:1:4)

19
20
21
22.1
22.2

Percent of children, 6 months through 17 years, who are vaccinated annually against seasonal influenza

22.3

Percent of adolescents, ages 13 through 17, who have received at least one dose of the HPV vaccine

22.4

Percent of adolescents, ages 13 through 17, who have received at least one dose of the Tdap vaccine

22.5

Percent of adolescents, ages 13 through 17, who have received at least one dose of the meningococcal
conjugate vaccine

23
24

Teen birth rate, ages 15 through 19, per 1,000 females
Percent of women who experience postpartum depressive symptoms following a recent live birth

25

Percent of children, ages 0 through 17, who were not able to obtain needed health care in the last year

26

OUTCOME MEASURE 1

Percent of pregnant women who receive
prenatal care beginning in the first trimester

GOAL

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

DEFINITION

Numerator:
Number of live births with reported first prenatal visit during the
first trimester (before 13 weeks’ gestation) in the calendar year
Denominator:
Number of live births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Early prenatal care is essential for identification of maternal
disease and risks for complications of pregnancy or birth. This
can help ensure that women with complex problems, chronic
illness, or other risks are seen by specialists. Early prenatal
care can also provide important education and counseling on
modifiable risks in pregnancy, including smoking, drinking, and
inadequate or excessive weight gain. Although early highquality prenatal care is essential, particularly for women with
chronic conditions or other risk factors, it may not be sufficient
to assure optimal pregnancy outcomes. Efforts to improve
pregnancy outcomes and the health of mothers and infants
should begin prior to conception, whether before a first or
subsequent pregnancy. As many women are not aware of
being pregnant at first, it is important to establish healthy
behaviors and achieve optimal health well before pregnancy.
Centers for Disease Control and Prevention. Pregnancy and
prenatal care.
https://www.cdc.gov/healthcommunication/toolstemplates/enter
tainmented/tips/PregnancyPrenatalCare.html
Centers for Disease Control and Prevention.
Recommendations to improve preconception health and health
care—United States. MMWR Recommendations and Reports.
2006;55(RR-06):1–23.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm

27

OUTCOME MEASURE 2

Rate of severe maternal morbidity per 10,000
delivery hospitalizations

GOAL

To reduce life-threatening maternal illness and complications.

DEFINITION

Numerator:
Number of delivery hospitalizations with an indication of severe
morbidity from ICD-10 diagnosis or procedure codes (e.g. heart
or kidney failure, stroke, embolism, hemorrhage).
Denominator:
Number of delivery hospitalizations
Units: 10,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Maternal, Infant, and Child Health (MICH) 5.
Reduce the rate of maternal mortality. (Baseline:12.7 maternal
deaths per 100,000 live births in 2007, Target: 11.4 maternal
deaths per 100,000 live births)
Related to Maternal, Infant, and Child Health (MICH) 6. Reduce
maternal illness and complications due to pregnancy
(complications during hospitalized labor and delivery) .
(Baseline: 31.1%, Target: 28%)

DATA SOURCES and DATA
ISSUES

Healthcare Cost and Utilization Project (HCUP) - State
Inpatient Database (SID)

SIGNIFICANCE

Severe maternal morbidity is more than 100 times as common
as pregnancy-related mortality—affecting about 52,000 women
annually—and it is estimated to have increased by 75 percent
over the past decade. Rises in chronic conditions, including
obesity, diabetes, hypertension, and cardiovascular disease,
are likely to have contributed to this increase. Minority women
and particularly non-Hispanic black women have higher rates of
severe maternal morbidity. Non-Hispanic Black, Hispanic,
Asian/Pacific Islander, and American Indian/Alaska Native
women had 2.1, 1.3, 1.2, and 1.7 times, respectively, higher
rates of severe morbidity compared with non-Hispanic white
women.
Callaghan WM, Creanga AA, Kuklina EV. Severe maternal
morbidity among delivery and postpartum hospitalizations in the
United States. Obstet Gynecol. 2012 Nov:120(5):1029-36.
https://www.ncbi.nlm.nih.gov/pubmed/23090519
Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial
and ethnic disparities in severe maternal morbidity: a multistate
analysis, 2008-10. Am J Obstet Gynecol. 2014 May
210(5):435.e1-e8. http://www.ajog.org/article/S00029378(13)02153-4/abstract

28

OUTCOME MEASURE 3

Maternal mortality rate per 100,000 live births

GOAL

To reduce the maternal mortality rate.

DEFINITION

Numerator:
Number of deaths related to or aggravated by pregnancy, but
not due to accidental or incidental causes, and occurring within
42 days of the end of a pregnancy (follows WHO definition)
Denominator:
Number of live births
Units: 100,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) 5.
Reduce the rate of maternal mortality. (Baseline:12.7 maternal
deaths per 100,000 live births in 2007, Target: 11.4 maternal
deaths per 100,000 live births)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS) for states and
territories
United Nations Maternal Mortality Estimation Interagency
Group for the Freely Associated States in the Pacific Basin

SIGNIFICANCE

Maternal mortality is a sentinal indicator of health and health
care quality worldwide. After a century of general
improvement, the U.S. maternal mortality rate more than
doubled over the past decade. Although most of this increase
was likely due to changes in the ascertainment and
identification of maternal deaths, at least part of the increase
appears to be real and may be attributable to increases in
chronic health conditions, such as cardiovascular disease and
diabetes. There are also significant racial disparities with Black
women having rates of maternal mortality at least 3 times that
of White women. Maternal deaths can be prevented or
reduced both by improving underlying maternal health as well
as health care quality for leading causes of maternal death,
such as hemmorhage and preeclampsia.
MacDorman MF, Declercq E, Cabral H, Morton C. Recent
Increases in the U.S. Maternal Mortality Rate: Disentangling
Trends From Measurement Issues. Obstet
Gynecol. 2016 Sep;128(3):447-55.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5001799/
CDC Pregnancy Mortality Surveillance System. Division of
Reproductive Health. National Center for Chronic Disease
Prevention and Health Promotion. 2017.
https://www.cdc.gov/reproductivehealth/
maternalinfanthealth/pmss.html

29

OUTCOME MEASURE 4

Percent of low birth weight deliveries (<2,500
grams)

GOAL

To reduce the percent of low birth weight deliveries

DEFINITION

Numerator:
Number of live births weighing less than 2,500 grams
Denominator:
Number of live births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
8.1: Reduce low birth weight (LBW). (Baseline: 8.2% in 2007,
Target 7.8%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Low birth weight infants include pre-term infants and infants
with intrauterine growth retardation. Some risk factors for low
birth weight babies include: chronic health conditions,
inadequate weight gain, both young and old maternal age,
poverty, smoking, substance abuse, and multiple births. Low
birth weight infants are more likely than normal weight infants to
die in the first year of life and to experience long-range physical
and developmental health problems. In 2013, 65% of all infant
deaths occurred to the 8% of low birth weight infants and over
half (53%) of all infant deaths occurred to the 1.4% of very low
birth weight infants. Infants born to non-Hispanic Black women
have the highest rates of low birth weight, particularly very low
birth weight, with levels that are about two or more times
greater than for infants born to women of other race and ethnic
groups.
March of Dimes. Low Birthweight. 2014 October.
http://www.marchofdimes.org/baby/low-birthweight.aspx
Mathews TJ, MacDorman MF, Thoma ME. Infant Mortality
Statistics From the 2013 Period Linked Birth/Infant Death Data
Set. National Vital Statistics Reports. 2015 August 6. 64(9).
https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf
Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data
for 2015. National vital statistics report; vol 66, no 1. Hyattsville,
MD: National Center for Health Statistics. 2017.
https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf

30

OUTCOME MEASURE 5

Percent of preterm births (<37 weeks)

GOAL

To reduce the percent of all preterm, early term, and early
elective deliveries.

DEFINITION

Numerator:
Number of live births before 37 weeks of complete gestation
Denominator:
Number of live births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
9.1: Reduce total preterm births (PTB). (Baseline:10.4% in
2007, Target 9.4%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Babies born preterm, before 37 completed weeks of gestation,
are at greater risk of immediate life-threatening health
problems, as well as long-term complications and
developmental delays. Currently, about 1 in every 10 infants
are born prematurely. Preterm birth is a leading cause of infant
death and childhood disability, accounting for at least a third of
all infant deaths. Although the risk of complications is greatest
among those babies who are born the earliest, even those
babies born “late preterm” (34 to 36 weeks’ gestation) and
"early term" (37, 38 weeks' gestation) are more likely than fullterm babies to experience morbidity and mortality. Infants born
to non-Hispanic Black women have the highest rates of preterm
birth, particularly early preterm birth, with levels that are at least
1.5 times those for infants born to women of other race and
ethnic groups. Risk factors include chronic conditions, obesity,
substance use, poverty, short birth intervals, and multiple
births.
Centers for Disease Control and Prevention. Preterm birth.
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pr
etermbirth.htm
Mathews TJ, MacDorman MF, Thoma ME. Infant Mortality
Statistics From the 2013 Period Linked Birth/Infant Death Data
Set. National Vital Statistics Reports. 2015 August 6. 64(9).
https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf
Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data
for 2015. National vital statistics report; vol 66, no 1. Hyattsville,
MD: National Center for Health Statistics. 2017.
https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf

31

OUTCOME MEASURE 6

Percent of early term births (37,38 weeks)

GOAL

To reduce the percent of all preterm, early term, and early elective
deliveries.

DEFINITION

Numerator:
Number of live births born at 37,38 weeks of completed gestation
Denominator:
Number of live births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Although the risk is less than for preterm babies, those born “early
term” at 37 or 38 completed weeks of gestation, are still at greater
risk of immediate health problems and long-term complications
compared to “full term” (39, 40 weeks completed gestation)
infants. In 2015, 25% of all births were early term. Complications
during the newborn period include respiratory distress and
neurological disorder, while long-term complications can include
learning and behavioral problems.
Martin JA, Hamilton BE, Osterman MJK et al. Births: Final Data for
2015. National Vital Statistics Reports. 2017 January 5. 66(1).
https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf
Gyamfi-Bannerman C. The scope of the problem: the
epidemiology of late preterm and early-term birth. Semin Perinatol.
2011 Oct;35(5):246-8.
https://www.ncbi.nlm.nih.gov/pubmed/21962621

32

OUTCOME MEASURE 7

Percent of non-medically indicated early elective
deliveries

GOAL

To reduce the percent of all preterm, early term, and early
elective deliveries.

DEFINITION

Numerator:
Number of inductions or cesareans without labor or
spontaneous rupture of membranes among deliveries at 37, 38
weeks' gestation without conditions possibly justifying elective
delivery <39 weeks according to The Joint Commission
Denominator:
Number of deliveries at 37, 38 weeks' gestation without
conditions possibly justifying elective delivery <39 weeks
according to The Joint Commission
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

CMS Hospital Compare

SIGNIFICANCE

Non-medically indicated early term births (37,38 weeks) present
avoidable risks of neonatal morbidity and costly NICU
admission. Early elective delivery prior to 39 weeks is an
endorsed perinatal quality measure by the Joint Commission,
National Quality Forum, ACOG/NCQA, Leapfrog Group, and
CMS/CHIPRA.
Tita AT, Landon MB, Spong CY et al. Timing of Elective Repeat
Cesarean Delivery at Term and Neonatal Outcomes. N Engl J
Med. 2009 Jan 8. 360(2): 111-20.
http://www.nejm.org/doi/full/10.1056/NEJMoa0803267
Clark SL, Miller DD, Belfort MA et al. Neonatal and Maternal
Outcomes Associated with Elective Term Delivery. Am J Obstet
Gynecol. 2009 February. 200(2):156.e1-4.
https://www.ncbi.nlm.nih.gov/pubmed/19110225

33

OUTCOME MEASURE 8

Perinatal mortality rate per 1,000 live births plus
fetal deaths

GOAL

To reduce the rate of perinatal deaths.

DEFINITION

Numerator:
Number of fetal deaths 28 weeks or more gestation plus early
neonatal deaths occurring under 7 days
Denominator:
Number of live births plus fetal deaths at 28 weeks or more
gestation
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Perinatal mortality is a reflection of the health of the pregnant
woman and newborn as well as the quality of perinatal care.
Risk factors for perinatal mortality include smoking during
pregnancy, maternal obesity, uncontrolled hypertension or
diabetes, infections and previous poor pregnancy outcome. In
2013, the rate of perinatal mortality was 6.24 perinatal deaths
per 1,000 live births and fetal deaths. The perinatal mortality
rate is particularly high for non-Hispanic Black women. In
2013, the rate for non-Hispanic black women (10.75) was the
highest among the racial and ethnic groups, and was more than
twice the rate for non-Hispanic white women (5.25).
MacDorman MF, Gregory ECW. Fetal and Perinatal Mortality:
United States, 2013. National Vital Statistics Reports. 2015 July
23. 64(8).
https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_08.pdf

34

OUTCOME MEASURE 9.1

Infant mortality rate per 1,000 live births

GOAL

To reduce the rate of infant death.

DEFINITION

Numerator:
Number of deaths to infants from birth through 364 days of age
Denominator:
Number of live births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS) for states and
territorities
United Nations Interagency Group for Child Mortality Estimation
for the Freely Associated States in the Pacific Basin

SIGNIFICANCE

Infant mortality, or the death of a child within the first year of life,
is a sentinel measure of population health that reflects the
underlying well-being of mothers and families, as well as the
broader community and social environment that cultivate health
and access to health-promoting resources. After a period of
stagnation from 2000 to 2005, the U.S. infant mortality rate has
continued to decline to record low levels below 6 per 1,000 live
births. However, significant disparities continue to persist
between racial groups, especially for infants born to nonHispanic black, American Indian/Alaskan Native, and Puerto
Rican women. The infant mortality rate among non-Hispanic
blacks is more than twice that of non-Hispanic whites. Leading
causes of infant mortality include prematurity, birth defects, and
sudden unexpected infant deaths. Infant mortality continues to
be an extremely complex health issue with many medical,
social, and economic determinants.
U.S. Department of Health and Human Services, Health
Resources and Services Administration, Maternal and Child
Health Bureau. Child Health USA 2014. Rockville, Maryland:
U.S. Department of Health and Human Services, 2014.
https://mchb.hrsa.gov/chusa14/health-statusbehaviors/infants/infant-mortality.html
Mathews TJ, Driscoll AK. Trends in infant mortality in the United
States, 2005–2014. NCHS data brief, no 279. Hyattsville, MD:
National Center for Health Statistics. 2017.
https://www.cdc.gov/nchs/products/databriefs/db279.htm

35

OUTCOME MEASURE 9.2

Neonatal mortality rate per 1,000 live births

GOAL

To reduce the rate of neonatal deaths.

DEFINITION

Numerator:
Number of deaths to infants under 28 days
Denominator:
Number of live births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS) for states and
territorities
United Nations Interagency Group for Child Mortality Estimation
for the Freely Associated States in the Pacific Basin

SIGNIFICANCE

Neonatal deaths, within the first month of life, account for
approximately two-thirds of all infant deaths in the U.S.
Neonatal mortality is related to gestational age, low birth weight,
congenital malformations and health problems originating in the
perinatal period, such as infections or birth trauma. A significant
disparity exists in neonatal deaths between racial groups,
especially for infants born to Black women. Non-Hispanic black
women had the highest neonatal mortality rate in 2013 at 7.46,
2.2 times that for non-Hispanic white women (3.34). Neonatal
mortality rates were also higher for Puerto Rican (4.23),
American Indian/Alaska Native (4.11), and Mexican women
(3.51) than for non-Hispanic white women.
Mathews TJ, MacDorman MF, Thoma ME. Infant Mortality
Statistics From the 2013 Period Linked Birth/Infant Death Data
Set. National Vital Statistics Reports. 2015 August 6. 64(9).
https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf

36

OUTCOME MEASURE 9.3

Postneonatal mortality rate per 1,000 live births

GOAL

To reduce the rate of postneonatal deaths.

DEFINITION

Numerator:
Number of deaths to infants 28 through 364 days of age
Denominator:
Number of live births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Postneonatal deaths, which occur from one month up to one
year after birth, account for approximately one-third of all infant
deaths in the U.S. Postneonatal mortality is generally related to
Sudden Unexpected Infant Death (SUID)/Sudden Infant Death
Syndrome (SIDS), unintentional injuries and congenital
malformations. Similar to overall infant mortality, infants of nonHispanic black (3.65) and AIAN (3.5) women had the highest
postneonatal mortality rates of any group—more than twice
those for non-Hispanic white women (1.71) in 2013.
Mathews TJ, MacDorman MF, Thoma ME. Infant Mortality
Statistics From the 2013 Period Linked Birth/Infant Death Data
Set. National Vital Statistics Reports. 2015 August 6. 64(9).
https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf

37

OUTCOME MEASURE 9.4

Preterm-related mortality rate per 100,000 live
births

GOAL

To reduce the rate of preterm-related death.

DEFINITION

Numerator:
Number of deaths due to preterm-related causes. Causes are
defined as preterm-related if 75% or more of infants whose
deaths were attributed to that cause were born at at less than
37 weeks of gestation, and the cause of death was a direct
consequence of preterm birth based on a clinical evaluation and
review of the literature. This includes low birth weight, several
maternal complications, respiratory distress, bacterial sepsis,
etc. To be included as a preterm-related death, the infant must
have been born preterm (<37 completed weeks of gestation)
with the underlying cause of death assigned to one of the
following ICD-10 categories: K550, P000, P010, P011, P015,
P020, P021, P027, P070–P073, P102, P220–229, P250–279,
P280, P281, P360–369, P520–523, and P77.
Denominator:
Number of live births
Units: 100,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Preterm birth is a leading cause of infant mortality, accounting
for approximately one-third of all infant deaths. Preterm-related
mortality can be prevented both by reducing preterm birth as
well as improving access to risk-appropriate perinatal care for
infants born prematurely. Similar to preterm birth and overall
infant mortality, there are significant racial/ethnic disparities in
preterm-related mortality. In 2013, the preterm-related mortality
rates were highest for infants born to non-Hispanic black and
Puerto Rican women (3 and 1.5 times higher than non-Hispanic
white women). Preterm-related deaths account for over half of
the overall infant mortality gap between non-Hispanic blacks
and non-Hispanic whites and almost all of the gap between
Puerto-Ricans and non-Hispanic whites.
Mathews TJ, MacDorman MF, Thoma ME. Infant Mortality
Statistics From the 2013 Period Linked Birth/Infant Death Data
Set. National Vital Statistics Reports. 2015 August 6. 64(9).
https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf

38

OUTCOME MEASURE 9.5

Sleep-related Sudden Unexpected Infant Death
(SUID) rate per 100,000 live births

GOAL

To reduce the rate sleep-related SUIDs

DEFINITION

Numerator:
Number of sleep-related SUID deaths, including SIDS (R95),
unknown cause (R99), and accidental suffocation and
strangulation in bed (W75)
Denominator:
Number of live births
Units: 100,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
1.9: Reduce the rate of infant deaths from sudden unexpected
infant deaths (includes SIDS, Unknown Cause, Accidental
Suffocation, and Strangulation in Bed). (Baseline: .93 per 1,000
live births in 2006, Target: .84 infant deaths per 1,000 live
births)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Sleep-related SUIDs are the leading cause of death in infants
from one month up to one year (postneonatal deaths) and
account for approximately 15% of all infant deaths. SUID rates
vary greatly by race and ethnicity. In 2013, SUID rates were
highest for infants born to non-Hispanic black mothers and
American Indian/Alaska Native (173 and 170 SUIDs per
100,000 live births, respectively); these rates were more than
twice the rate among infants born to non-Hispanic whites (85
SUIDs per 100,000 live births). SUIDs account for 33% of the
overall infant mortality gap between American Indian/Alaska
Native and non-Hispanic whites and 15% of the gap between
non-Hispanic blacks and non-Hispanic whites. To reduce
SUIDs, the American Academy of Pediatrics recommends safe
sleep practices, such as placing babies to sleep on their backs
on a separate firm sleep surface without soft objects or loose
bedding, as well as other protective practices such as
breastfeeding and smoking cessation.
Mathews TJ, MacDorman MF, Thoma ME. Infant Mortality
Statistics From the 2013 Period Linked Birth/Infant Death Data
Set. National Vital Statistics Reports. 2015 August 6. 64(9).
https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf
Taskforce on Sudden Infant Death Syndrome. SIDS and Other
Sleep-Related Infant Deaths: Updated 2016 Recommendations
for a Safe Infant Sleeping Environment. Pediatrics. 2016
Nov;138(5).
http://pediatrics.aappublications.org/content/138/5/e20162938

39

OUTCOME MEASURE 10

The percent of infants born with fetal alcohol
exposure in the last 3 months of pregnancy

GOAL

To reduce the percent of infants born with fetal alcohol
exposure

DEFINITION

Numerator:
Number of women who report drinking alcohol in the last 3
months of pregnancy
Denominator:
Number of live births
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH) 11.1.
Increase abstinence from alcohol among pregnant women.
(Baseline: 89.4 percent of pregnant females ages15 to 44
years reported abstaining from alcohol in the past 30 days in
2007–08, Target: 98.3%)
Related to Maternal, Infant, and Child Health (MICH) 25.
Reduce the occurrence of fetal alcohol syndrome. (Baseline:
3.6 cases of fetal alcohol syndrome per 10,000 live births in
2006 were suspected or confirmed among children born in
2001–04, Target: Not Applicable)

DATA SOURCES and DATA
ISSUES

Pregnancy Risk Assessment Monitoring System (PRAMS)

SIGNIFICANCE

Fetal alcohol spectrum disorders (FASDs), which result in lifelong physical and cognitive or behavioral problems, are caused
by drinking during pregnancy. Fetal alcohol syndrome (FAS)
represents the severe end of FASDs, and is characterized by
abnormal facial features (e.g., smooth ridge between nose and
upper lip), lower than average height or weight, and central
nervous system problems that create deficits in learning,
memory, attention, communication, vision, and/or hearing.
FASDs are preventable through abstinence from alcohol
among pregnant women. Early diagnosis and intervention
programs are critical to improve developmental outcomes for
children with FAS.
Centers for Disease Control and Prevention. Fetal Alcohol
Spectrum Disorder (FASDs). 2015 April 16.
https://www.cdc.gov/ncbddd/fasd/facts.html

40

OUTCOME MEASURE 11

The rate of infants born with neonatal
abstinence syndrome per 1,000 hospital
births

GOAL

To reduce the rate of infants born with drug dependency.

DEFINITION

Numerator:
Number of infants born with neonatal abstinence syndrome
Denominator:
Number of hospital births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health Objective 11.4.
Increase abstinence from illicit drugs among pregnant women.
(Baseline: 94.8 percent of pregnant females ages 15 to 44
years reported abstaining from illicit drugs in the past 30 days in
2007–08; Target 100%)

DATA SOURCES and DATA
ISSUES

Healthcare Cost and Utilization Project (HCUP) - State Inpatient
Database (SID)

SIGNIFICANCE

Neonatal drug dependency or withdrawal symptoms, known as
neonatal abstinence syndrome (NAS), occur from maternal use
of opiates such as heroin, methadone, and prescription pain
medications. Symptoms of NAS include fever, diarrhea,
irritability, trembling, and increased muscle tone. Along with a
rise in prescription drug abuse, the incidence of NAS nearly
tripled over the past decade with substantial increases in health
care costs. Prevention strategies exist along the continuum
from preconception, prenatal, postpartum, and infant/childhood
stages to help avert substance-exposed pregnancies and
improve outcomes for infants born with NAS.
Patrick SW, Shumacher RE, Benneyworth BD et al. Neonatal
Abstinence Syndrome and Associated Health Care
Expenditures, 2000-2009. JAMA. 2012 May 9. 307(18):193440. http://jamanetwork.com/journals/jama/fullarticle/1151530
Association of State and Territorial Health Officials (ASTHO).
Neonatal Abstinence Syndrome: How States Can Help Advance
the Knowledge Base for Primary Prevention and Best Practices
of Care. 2014. http://www.astho.org/prevention/nas-neonatalabstinence-report/
Ko JY, Wolicki S, Barfield WD, et al. CDC Grand Rounds:
Public Health Strategies to Prevent Neonatal Abstinence
Syndrome. MMWR Morb Mortal Wkly Rep 2017;66:242–245.
DOI: http://dx.doi.org/10.15585/mmwr.mm6609a2

41

OUTCOME MEASURE 12

Percent of eligible newborns screened for
heritable disorders with on time physician
notification for out of range screens who are
followed up in a timely manner.
(DEVELOPMENTAL)

GOAL

To increase the percent of eligible newborns screened for
heritable disorders with on-time physician notification for out of
range screens and timely follow up.

DEFINITION

Numerator:
Number of eligible newborns screened for heritable disorders
with on time physician notification for out of range screens who
are followed up in a timely manner. UNDER DEVELOPMENT.
Denominator:
Number of live eligible births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
32: Increase appropriate newborn blood-spot screening and
follow-up testing (Baseline: 98.3% of screen-positive children
received follow-up testing within the recommended time period
in 2003–06, Target: 100%).

DATA SOURCES and DATA
ISSUES

The American Public Health Laboratories (APHL) data set

SIGNIFICANCE

Newborn screening detects thousands of babies each year with
potentially devastating, but treatable disorders. The benefits of
newborn screening depend upon timely collection of the
newborn blood-spots or administration of a point-of-care test
(pulse oximeter for critical congenital heart disease (CCHD)),
receipt of the newborn blood spot at the laboratory, testing of
the newborn blood spot, and reporting out of all results. Timely
detection prevents death, mental retardation, and other
significant health complications.
Centers for Disease Control and Prevention. CDC Grand
Rounds: Newborn Screening and Improved Outcomes.
Morbidity and Mortality Weekly Report. 2012 June 1. 61(21):
390-93. https://www.cdc.gov/mmwr/pdf/wk/mm6121.pdf

42

OUTCOME MEASURE 13

Percent of children meeting the criteria
developed for school readiness
(DEVELOPMENTAL)

GOAL

To increase the percent of children ready for school.

DEFINITION

Numerator:
Under development
Denominator:
Under development
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Early and Middle Childhood (EMC) 1.
(Developmental) Increase the proportion of children who are
ready for school in all five domains of healthy development:
physical development, social-emotional development,
approaches to learning, language, and cognitive development.

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH).

SIGNIFICANCE

The early years are a critical period where experiences impact
structural development of the brain and neurobiological
pathways for functional development. Although early
experiences do not determine children’s ongoing development,
interventions around school readiness and early childhood
education can act as a protective factor against the future onset
of adult disease and disability. Studies have shown that
children’s literacy and numeracy skills at school entry are a
good predictor of later academic achievement, high levels of
education and secure employment. Social gradients in language
and literacy, communication and socioemotional functioning
emerge early for children across socioeconomic backgrounds,
and these differences persist into the school years. There are
also disparities in the US as to who participates in an early
childhood program. Children at risk of poor developmental and
educational outcomes benefit from attending high-quality
education and care programs in the years before school.
Centers for Disease Control and Prevention. Early Childhood
Education. 2016 August 5.
https://www.cdc.gov/policy/hst/hi5/earlychildhoodeducation/
Child Trends: Data Bank. Early School Readiness. 2015 July.
https://www.childtrends.org/wpcontent/uploads/2015/07/07_School_Readiness.pdf

43

OUTCOME MEASURE 14

Percent of children, ages 1 through 17, who
have decayed teeth or cavities in the past year

GOAL

To reduce the percent of children and adolescents who have
dental caries or decayed teeth.

DEFINITION

Numerator:
Number of children ages 1 through 17 who have decayed teeth
or cavities in the past year
Denominator:
Number of children, ages 1 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Oral Health of Children and Adolescents (OH)
Objectives 1.1 : Reduce the proportion of children ages 3-5 who
have dental caries experience in their primary or permanent
teeth, (Baseline: 33.3%, Target: 30.0%), 1.2: Reduce the
proportion of children ages 6-9 who have dental caries
experience in their primary or permanent teeth (Baseline:
54.4%, Target: 49.0%) and 1.3: Reduce the proportion of
adolescents aged 13 to 15 years with dental caries experience
in their permanent teeth (Baseline: 53.7%, Target: 48.3%).

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Tooth decay (cavities) is among the most common chronic
conditions of childhood. Untreated tooth decay can lead to pain
and infections which may result in problems with eating,
speaking, learning and playing. Children with poor oral health
tend to miss more school and get lower grades than those who
do not. Tooth decay can be prevented through recommended
preventive dental care, including flouride varnish and dental
sealants, community water flouridation, and oral hygeine
practices, including brushing and flossing.
Centers for Disease Control and Prevention. Children’s Oral
Health. 2016 November 15.
https://www.cdc.gov/oralhealth/basics/childrens-oralhealth/index.html

44

OUTCOME MEASURE 15

Child mortality rate, ages 1 through 9, per
100,000

GOAL

To reduce the death rate of children ages 1 through 9.

DEFINITION

Numerator:
Number of deaths among children ages 1 through 9 years
Denominator:
Number of children ages 1 through 9 years
Units: 100,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Maternal, Infant, and Child Health (MICH) Objective
3.1: Reduce the rate of child deaths aged 1 to 4 years.
(Baseline: 29.4 deaths among children aged 1 to 4 years per
100,000 population occurred in 2007, Target: 26.5 deaths per
100,000 population)
Related to Objective Maternal, Infant, and Child Health (MICH)
3.2: Reduce the rate of child deaths aged 5 to 9 years.
(Baseline: 13.8 deaths among children aged 5 to 9 years per
100,000 population occurred in 2007, Target: 12.4 deaths per
100,000 population)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)
Population estimates come from the U.S. Census Bureau

SIGNIFICANCE

Although the risk of death for children declines sharply beyond
infancy, there were still over 6,000 deaths among U.S. children
ages 1 through 9 in 2014. Unintentional injury continues to be
the leading cause of death in children 1 to 9 years. Other
leading causes include congenital malformations, malignant
neoplasms, and homicide.
Heron M. Deaths: Leading Causes for 2014. National Vital
Statistics Reports. 2016 June 30. 65(5).
https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_05.pdf

45

OUTCOME MEASURE 16.1

Adolescent mortality rate, ages 10 through 19,
per 100,000

GOAL

To reduce the death rate of adolescents ages 10 through 19.

DEFINITION

Numerator:
Number of deaths among adolescents ages 10 through 19
years
Denominator:
Number of adolescents ages 10 through 19 years
Units: 100,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Objective Maternal, Infant, and Child Health (MICH)
4.1: Reduce the rate of adolescent deaths aged 10 to 14 years.
(Baseline: 16.5 deaths among adolescents aged 10 to 14 years
per 100,000 population occurred in 2007, Target: 14.8 deaths
per 100,000)
Related to Objective Maternal, Infant, and Child Health (MICH)
4.2: Reduce the rate of adolescent deaths aged 15 to 19 years.
(Baseline: 60.3 deaths among adolescents aged 15 to 19 years
per 100,000 population occurred in 2007, Target: 54.3 deaths
per 100,000)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)
Population estimates come from the U.S. Census Bureau

SIGNIFICANCE

Although the risk of death declines sharply in early childhood,
mortality rates begin to increase again in adolescence. Over
12,000 deaths occurred among U.S. children ages 10 through
19 in 2014. The leading causes of illness and death among
adolescents and young adults are largely preventable.
Unintentional injury continues to be the leading cause of death
in adolescents 10 to 19 years, accounting for 36% percent of all
deaths, followed by suicide (18%), homicide (13%), and
malignant neoplasms (8%).
Heron M. Deaths: Leading Causes for 2014. National Vital
Statistics Reports. 2016 June 30. 65(5).
https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_05.pdf

46

OUTCOME MEASURE 16.2

Adolescent motor vehicle mortality rate, ages 15
through 19, per 100,000

GOAL

To reduce the death rate of adolescents ages 15 through 19
from motor vehicle crashes

DEFINITION

Numerator:
Number of deaths to adolescents ages 15 through 19 years
caused by motor vehicle crashes. This includes all occupant,
pedestrian, motorcycle, bicycle, etc. deaths caused by motor
vehicles.
Denominator:
Number of adolescents ages 15 through 19 years
Units: 100,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Objective IVP-13: Reduce motor vehicle crashrelated deaths. (Baseline: 13.8 motor vehicle traffic-related
deaths per 100,000 population occurred in 2007, Target: 12.4
deaths per 100,000 population)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)
Population estimates come from the U.S. Census Bureau

SIGNIFICANCE

More than one-third of all teen deaths are the result of a motor
vehicle crash. Teenage drivers have crash rates that are nearly
three times those of drivers older than 20 years. Factors related
to lack of driving experience and maturity contribute to motor
vehicle mortality, such as driving too fast, violating traffic
signals, alcohol use and presence of other teenage
passengers. Motor vehicle death rates greatly increase during
the teen years and stay high into early adulthood. Males are
nearly twice as likely as females to die in motor vehicle
accidents. Non-Hispanic white male and American
Indian/Alaskan male adolescents have the highest motor
vehicle mortality rate among 15-19 year olds.
Child Trends: Data Bank. Motor Vehicle Deaths-Indicators on
Children and Youth. 2015 December.
https://www.childtrends.org/wpcontent/uploads/2012/11/77_Vehicle_Deaths.pdf

47

OUTCOME MEASURE 16.3

Adolescent suicide rate, ages 15 through 19, per
100,000

GOAL

To eliminate self-induced, preventable morbidity and mortality.

DEFINITION

Numerator:
Number of deaths attributed to suicide among adolescents ages
15 through 19 years
Denominator:
Number of adolescents ages 15 through 19 years
Units: 100,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Mental Health and Mental Disorders (MHMD)
Objective 1: Reduce the suicide rate. (Baseline: 11.3 suicides
per 100,000 in 2007, Target: 10.2 suicides per 100,000)
Related to Mental Health and Mental Disorders (MHMD)
Objective 2: Reduce suicide attempts by adolescents.
(Baseline: 1.9 suicide attempts per 100 occurred in 2009,
Target: 1.7 suicide attempts per 100)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)
Population estimates come from the U.S. Census Bureau

SIGNIFICANCE

Suicide is the second leading cause of death for adolescents
ages 15 through 19 years. In 2014, there were over 2,000
deaths due to suicide among adolescents ages 15 to 19 years,
or 9.8 deaths per 100,000. Suicide and suicidal ideation is often
indicative of mental health problems and stressful or traumatic
life events. In 2015, 18 percent of high school students reported
they had thought seriously about committing suicide in the past
year. While females are more likely to report considering
suicide, males are more likely to succeed in committing suicide.
The suicide mortality rate for males is nearly three times that of
females.
Heron M. Deaths: Leading Causes for 2014. National Vital
Statistics Reports. 2016 June 30. 65(5).
https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_05.pdf
Child Trends: Data Bank. Suicidal Teens-Indicators of Child and
Youth Well-Being. 2016 December.
https://www.childtrends.org/wpcontent/uploads/2016/12/34_Suicidal_Teens.pdf

48

OUTCOME MEASURE 17.1

Percent of children with special health care
needs (CSHCN), ages 0 through 17

GOAL

To track the percent of children and youth with special health
care needs, autism spectrum disorder (ASD), and attention
deficit disorder/attent deficit hyperactivity disorder
(ADD/ADHD).

DEFINITION

Numerator:
Number of children, ages 0 through17, who met the criteria for
having a special health care need based on the CSHCN
screener
Denominator:
Number of children, ages 0 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Children are considered to have a special health care need if,
in addition to a chronic medical, behavioral, or developmental
condition that has lasted or is expected to last 12 months or
longer, they experience either service-related or functional
consequences, including the need for or use of prescription
medications and/or specialized therapies. The percent of
children with special health care needs has been increasing
since 2001. About 1 in 5 of all US children are considered to
have special health care needs. However, they account for
almost half of all health care expenditures for children.
U.S. Department of Health and Human Services, Health
Resources and Services Administration, Maternal and Child
Health Bureau. Child Health USA 2014. Rockville, Maryland:
U.S. Department of Health and Human Services, 2014.
https://mchb.hrsa.gov/chusa14/populationcharacteristics/children-special-health-care-needs.html

49

OUTCOME MEASURE 17.2

Percent of children with special health care
needs (CSHCN), ages 0 through 17, who receive
care in a well-functioning system

GOAL

To ensure access to needed and continuous systems of care
for children and youth with special health care needs.

DEFINITION

Numerator:
Number of CSHCN ages 0 through 17 that received all
components of a well-functioning system (family partnership,
medical home, early screening, adequate insurance, easy
access to services, and preparation for adult transition)
Denominator:
Number of CSHCN ages 0 through 17
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH) Objectives
30.1 : Increase the proportion of children who have access to a
medical home, (Baseline: 57.5%, Target: 63.3%) and 30.2:
Increase the proportion of children with special health care
needs who have access to a medical home. (Baseline: 49.8%,
Target: 54.8%)
Related to Objective Maternal, Infant, and Child Health (MICH)
31: Increase the proportion of children with special health care
needs who receive their care in family-centered,
comprehensive, coordinated systems. (Baseline: 20.4% for
children aged 0-11 Target: 22.4% Baseline: 13.8%, for
children aged 12 through 17, Target: 15.2%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

According to the 2009-10 NS-CSHCN, only 17.6% of CSHCN
receive services in a well-functioning system of services. The
Omnibus Budget Reconciliation Act of 1989 requires Title V to
provide and promote family-centered, community-based,
coordinated care and facilitate the development of communitybased systems of services for children with special health care
needs and their families. To address this requirement a
minimum of 30 percent of the Title V Block Grant funding is
allocated for this purpose, and HP 2020 Objective MICH-31
establishes the goal to increase the proportion of children with
special health care needs who receive their care in familycentered, comprehensive, and coordinated systems.
Strickland BB, Jones JR, Newacheck PW, Bethell CD,
Blumberg SJ, Kogan MD. Assessing systems quality in a
changing health care environment: the 2009-10 national survey
of children with special health care needs. Matern Child Health
J. 2015 Feb;19(2):353-61.
https://www.ncbi.nlm.nih.gov/pubmed/24912943

50

OUTCOME MEASURE 17.3

Percent of children, ages 3 through 17,
diagnosed with an autism spectrum disorder

GOAL

To track the percent of children and youth with special health
care needs, autism spectrum disorder (ASD), and attention
deficit disorder/attention deficit hyperactivity disorder
(ADD/ADHD).

DEFINITION

Numerator:
Number of children, ages 3 through 17, reported by their
parents to have been diagnosed by a health care provider with
ASD and to currently have the condition
Denominator:
Number of children, ages 3 through17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Autism spectrum disorder (ASD) is a developmental disability
that can cause significant social, communication and
behavioral challenges. The prevalence of ASD has risen
sharply over the last two decades. However, the average age
at diagnosis for ASD is 4 years old, while the American
Academy of Pediatrics recommends screening beginning at
nine months. Interventions for ASD are more effective when
they're started earlier.
https://www.cdc.gov/ncbddd/autism/index.html

51

OUTCOME MEASURE 17.4

Percent of children, ages 3 through 17,
diagnosed with Attention Deficit
Disorder/Attention Deficit Hyperactivity Disorder
(ADD/ADHD)

GOAL

To track the percent of children and youth with special health
care needs, autism spectrum disorder (ASD), and attention
deficit disorder/attent deficit hyperactivity disorder
(ADD/ADHD).

DEFINITION

Numerator:
Number of children, ages 3 through 17, reported by their
parents to have been diagnosed by a health care provider with
ADD/ADHD and to currently have the condition
Denominator:
Number of children, ages 3 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Attention-deficit/hyperactivity disorder (ADHD) is one of the
most common neurobehavioral disorders of childhood. The
prevalence has been increasing over the last decade for
reasons that are not yet clear. It is sometimes referred to as
Attention Deficit Disorder (ADD). It is usually first diagnosed in
childhood and often lasts into adulthood. Children with ADHD
may have trouble paying attention, controlling impulsive
behaviors, or be overly active.
https://www.cdc.gov/ncbddd/adhd/index.html

52

OUTCOME MEASURE 18

Percent of children, ages 3 through 17, with a
mental/behavioral condition who receive
treatment or counseling

GOAL

To increase the percent of children with a mental/behavioral
condition who receive treatment or counseling.

DEFINITION

Numerator:
Number of children, ages 3 through 17, reported by their
parents to have been diagnosed by a health care provider with
a mental/behavioral condition (depression, anxiety problems, or
behavioral or conduct problems) who currently have the
condition and received treatment or counseling in the last year
Denominator:
Number of children, ages 3 through 17, reported by their
parents to have been diagnosed by a health care provider with
a mental/behavioral condition (depression, anxiety problems, or
behavioral or conduct problems) who currently have the
condition
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Mental Health and Mental Disorders Objective 6:
Increase the proportion of children with mental health problems
who receive treatment (Baseline: 68.9% in 2008, Target:
75.0%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

The prevalence of mental/behavioral health conditions has
been increasing among children and has been found to vary by
geographic and sociodemographic factors. However, a
significant portion of children diagnosed with a mental health
condition do not receive treatment. Further, the receipt of
treatment is generally dependent on sociodemographic and
health-related factors. Adequate insurance and access to a
patient-centered medical home may improve mental health
treatment.
Ghandour RM, Kogan MD, Blumberg SJ, Jones JR, Perrin JM.
Mental health conditions among school-aged children:
geographic and sociodemographic patterns in prevalence and
treatment. J Dev Behav Pediatr. 2012 Jan;33(1):42-54.
https://www.ncbi.nlm.nih.gov/pubmed/22218014

53

OUTCOME MEASURE 19

Percent of children, ages 0 through 17, in
excellent or very good health

GOAL

To improve the health status of children.

DEFINITION

Numerator:
Number of children ages 0 through 17 reported by their parents
to be in excellent or very good health
Denominator:
Number of children ages 0 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Health-Related Quality of Life and Well-being
Objective 1.1: Increase the proportion of adults who self-report
good or better physical health
(Baseline: 78.8%.Target: 79.8%)
and Objective 1.2: Increase the proportion of adults who selfreport good or better mental health
(Baseline: 79.1%.Target: 80.1%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Overall health status for children provides a global, summary
measure of children’s health and well-being. Children reported
to be in excellent or very good health are more likely to thrive in
a variety of health dimensions, including physical and mental
health. Self or proxy-reported health status is an indicator of
health-related quality of life that is often more predictive of
morbidity and mortality than objective measures of health.
Centers for Disease Control and Prevention. Health-Related
Quality of Life. https://www.cdc.gov/hrqol/concept.htm

54

OUTCOME MEASURE 20

Percent of children, ages 2 through 4, and
adolescents, ages 10 through 17, who are obese
(BMI at or above the 95th percentile)

GOAL

To reduce the percent of children and adolescents who are
considered obese.

DEFINITION

Numerator:
Number of children ages 2 through 4 who are obese (WIC)
Number of adolescents ages 10 through 17 who are obese
(NSCH)
Number of adolescents in grades 9 through 12 who are obese
(YRBSS)
Denominator:
Number of children ages 2 through 4 (WIC)
Number of adolescents ages 10 through 17 (NSCH)
Number of adolescents in grades 9 through 12 (YRBSS)
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Nutrition and Weight Status (NWS) 10.4. Reduce
the proportion of children and adolescents aged 2 to 19 years
who are considered obese. (Baseline: 16.1% in 2005-2008,
Target: 14.5%).
Related to NWS 11. (Developmental) Prevent inappropriate
weight gain in youth and adults.

DATA SOURCES and DATA
ISSUES

Children 2 through 4 years: Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC)
Adolescents 10 through 17 years (parent report): National
Survey of Children’s Health (NSCH)
Adolescents grades 9 through 12 (adolescent report): Youth
Risk Behavior Surveillance System (YRBSS)

SIGNIFICANCE

Childhood obesity is a serious health problem in the United
States, that has tripled in prevalence since the 1970s.
Currently, about 1 in 5 school-aged children are obese.
Childhood obesity is associated with a variety of adverse
consequences, including an increased risk of cardiovascular
disease, type 2 diabetes, asthma, social stigmatization, low
self-esteem, and adult obesity. Obesity in adulthood is linked to
cardiovascular disease, type 2 diabetes, and cancer, and obese
children are likely to have more severe obesity and attendant
health problems in adulthood.
https://www.cdc.gov/healthyschools/obesity/facts.htm

55

OUTCOME MEASURE 21

Percent of children, ages 0 through 17, without
health insurance

GOAL

To ensure access to needed health care services for children.

DEFINITION

Numerator:
Number of children ages 0 through 17 who are not currently
covered by any private or public health insurance
Denominator:
Number of children ages 0 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

American Community Survey (ACS) and/or National Survey of
Children's Health (NSCH)

SIGNIFICANCE

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

56

OUTCOME MEASURE 22.1

Percent of children, ages 19 through 35 months,
who have completed the combined 7-vaccine
series (4:3:1:3*:3:1:4)

GOAL

To increase the percent of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Number of children, ages 19 through 35 months, who have
completed the combined 7-vaccine series of routinely
recommended vaccinations (4:3:1:3*:3:1:4)
Denominator:
Number of children, ages 19 through 35 months

Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Immunization and Infectious Disease (IID) 8.0:
Increase the percentage of children aged 19 to 35 months who
receive the recommended doses of DTaP, polio, MMR, Hib,
hepatitis B, varicella and pneumococcal conjugate vaccine
(PCV) (Baseline in 2009 of 44.3%, Target of 80.0%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey (NIS)

SIGNIFICANCE

Vaccination is one of the greatest public health achievements
of the 20th century, resulting in dramatic declines in morbidity
and mortality for many infectious diseases. Childhood
vaccination in particular is considered among the most costeffective preventive services available, as it averts a potential
lifetime lost to death and disability. Currently, there are 12
different vaccines recommended by the Centers for Disease
Control and Prevention from birth through age 18, many of
which require multiple doses for effectiveness as well as
boosters to sustain immunity.
https://www.cdc.gov/vaccines/index.html

57

OUTCOME MEASURE 22.2

Percent of children, ages 6 months through 17
years, who are vaccinated annually against
seasonal influenza

GOAL

To increase the percent of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Number of children 6 months through 17 years who are
vaccinated annually against seasonal influenza
Denominator:
Number of children, ages 6 months through 17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Immunization and Infectious Disease (IID) 12.11.
Increase the percentage of children aged 6 months through 17
years who are vaccinated annually against seasonal influenza
(Baseline of 46.9% in 2010-11 flu season, Target of 70%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey - Flu (NIS-Flu)

SIGNIFICANCE

Vaccination is one of the greatest public health achievements
of the 20th century, resulting in dramatic declines in morbidity
and mortality for many infectious diseases. Childhood
vaccination in particular is considered among the most costeffective preventive services available, as it averts a potential
lifetime lost to death and disability. Currently, there are 12
different vaccines recommended by the Centers for Disease
Control and Prevention from birth through age 18, many of
which require multiple doses for effectiveness as well as
boosters to sustain immunity.
https://www.cdc.gov/vaccines/index.html

58

OUTCOME MEASURE 22.3

Percent of adolescents, ages 13 through 17, who
have received at least one dose of the HPV
vaccine

GOAL

To increase the percent of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Number of adolescents, ages 13 through17, who have received
at least one dose of the HPV vaccine
Denominator:
Number of adolescents, ages 13 through17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Immunization and Infectious Disease (IID) 11.4
Increase the vaccination coverage level of 3 doses of human
papillomavirus (HPV) vaccine for females by age 13 to 15
years (Baseline in 2008 of 16.6%, Target of 80%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey - Teen (NIS-Teen)

SIGNIFICANCE

Vaccination is one of the greatest public health achievements
of the 20th century, resulting in dramatic declines in morbidity
and mortality for many infectious diseases. Childhood
vaccination in particular is considered among the most costeffective preventive services available, as it averts a potential
lifetime lost to death and disability. Currently, there are 12
different vaccines recommended by the Centers for Disease
Control and Prevention from birth through age 18, many of
which require multiple doses for effectiveness as well as
boosters to sustain immunity.
https://www.cdc.gov/vaccines/index.html

59

OUTCOME MEASURE 22.4

Percent of adolescents, ages 13 through 17, who
have received at least one dose of the Tdap
vaccine

GOAL

To increase the percent of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Number of adolescents, ages 13 through17, who have
received at least one dose of the Tdap vaccine
Denominator:
Number of adolescents, ages 13 through17 years

Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Immunization and Infectious Disease (IID) 11.1.
Increase the vaccination coverage level of 1 dose of tetanusdiphtheria-acellular pertussis (Tdap) booster vaccine for
adolescents by age 13 to 15 years (Baseline 46.7% in 2008;
Target of 80%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey - Teen (NIS-Teen)

SIGNIFICANCE

Vaccination is one of the greatest public health achievements
of the 20th century, resulting in dramatic declines in morbidity
and mortality for many infectious diseases. Childhood
vaccination in particular is considered among the most costeffective preventive services available, as it averts a potential
lifetime lost to death and disability. Currently, there are 12
different vaccines recommended by the Centers for Disease
Control and Prevention from birth through age 18, many of
which require multiple doses for effectiveness as well as
boosters to sustain immunity.
https://www.cdc.gov/vaccines/index.html

60

OUTCOME MEASURE 22.5

Percent of adolescents, ages 13 through 17, who
have received at least one dose of the
meningococcal conjugate vaccine

GOAL

To increase the percent of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Number of adolescents, ages 13 through17, who have
received at least one dose of the meningococcal conjugate
vaccine
Denominator:
Number of adolescents, ages 13 through17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Immunization and Infectious Disease (IID)
11.3.Increase the vaccination coverage level of 1 dose
meningococcal conjugate vaccine for adolescents by age 13 to
15 years (Baseline 43.9% in 2008; Target 80%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey - Teen (NIS-Teen)

SIGNIFICANCE

Vaccination is one of the greatest public health achievements
of the 20th century, resulting in dramatic declines in morbidity
and mortality for many infectious diseases. Childhood
vaccination in particular is considered among the most costeffective preventive services available, as it averts a potential
lifetime lost to death and disability. Currently, there are 12
different vaccines recommended by the Centers for Disease
Control and Prevention from birth through age 18, many of
which require multiple doses for effectiveness as well as
boosters to sustain immunity.
https://www.cdc.gov/vaccines/index.html

61

OUTCOME MEASURE 23

Teen birth rate, ages 15 through 19, per 1,000
females

GOAL

To reduce pregnancies to teenagers.

DEFINITION

Numerator:
Number of births to adolescents, ages 15 through 19 years
Denominator:
Number of adolescent females, ages 15 through 19 years
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Family Planning (FP) 8.1: Reduce pregnancies
among adolescent females aged 15 to 17 years (Baseline 40.2
per 1,000 in 2005; Target 36.2 per 1,000) and FP 8.2: Reduce
pregnancies among adolescent females aged 17 to 19 years
(Baseline 116.2 per 1,000 in 2005; Target 105.9 per 1,000)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS) for states and
territories
Population estimates come from the U.S. Census Bureau
United Nations Population Division for the Freely Associated
States in the Pacific Basin

SIGNIFICANCE

Teen pregnancy and childbearing have substantial social and
economic costs for both teens and their children. Teen
mothers are less likely to complete high school and further
education which may reduce earning potential and contribute
to intergenerational poverty. Although teen pregnancy and
birth rates have declined substantially over the past two
decades, rates are still higher than in many other industrialized
countries and large racial/ethnic disparities persist. Birth rates
for non-Hispanic Black and Hispanic teens are more than
double that of non-Hispanic White teens.
https://www.cdc.gov/teenpregnancy/about/index.htm

62

OUTCOME MEASURE 24

Percent of women who experience postpartum
depressive symptoms following a recent live
birth

GOAL

To reduce the prevalence of postpartum depression

DEFINITION

Numerator:
Number of women who report postpartum depressive
symptoms following a recent live birth (defined as reporting
always/often feeling down, depressed, hopeless or
always/often having little interest or little pleasure in doing
things)
Denominator:
Number of women with a recent live birth
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) 34:
Decrease the proportion of women delivering a live birth who
experience postpartum depressive sympoms (Developmental)

DATA SOURCES and DATA
ISSUES

Pregnancy Risk Assessment Monitoring System (PRAMS)

SIGNIFICANCE

Postpartum depression is common, affecting as many as 1 in 7
mothers. It occurs when brief “baby blue” symptoms of crying,
sadness, and irritability become severe and result in
depressed mood and loss of interest in activities for more than
two weeks. Postpartum depression is associated with poor
maternal-infant bonding and may negatively influence child
development. Universal screening and treatment for pregnant
and postpartum women is recommended by the American
College of Obstetricians and Gynecologists (ACOG), the
American Academy of Pediatrics (AAP), and the U.S.
Preventive Services Task Force.
Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum
depression. American Journal of Obstetrics & Gynecology.
2009;200(4):357-364.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918890/
Screening for perinatal depression. Committee Opinion No.
630. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2015;125:1268–71.
http://www.acog.org/Resources-And-Publications/CommitteeOpinions/Committee-on-Obstetric-Practice/Screening-forPerinatal-Depression

63

OUTCOME MEASURE 25

Percent of children, ages 0 through 17, who
were not able to obtain needed health care in the
last year

GOAL

To ensure access to needed health care services for children.

DEFINITION

Numerator:
Number of children, ages 0 through 17 years, who were
reported by a parent to not able to obtain needed health care
in the last year
Denominator:
Number of children, ages 0 through 17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Access to Health Services (AHS) 6.1: Reduce the
proportion of persons who are unable to obtain or delay in
obtaining necessary medical care, dental care, or prescription
medicines (Baseline 10% in 2007; Target 9%)

DATA SOURCES and DATA
ISSUES

National Survey of Children’s Health (NSCH)

SIGNIFICANCE

Improving access to quality health services is essential for
optimal health in both preventing and treating health
conditions. When needed care is not received, health may
suffer and conditions may not be prevented or may grow in
severity. Common barriers to care include cost, language,
logistical, and structural factors, such as not having
transportation or scheduling difficulties. Adequate insurance
and access to a patient-centered medical home can reduce
unmet needs for health care.
Kogan MD, Newacheck PW, Blumberg SJ, Ghandour RM,
Singh GK, Strickland BB, van Dyck PC. Underinsurance
among children in the United States. N Engl J Med. 2010Aug
26;363(9):841-51.
http://www.nejm.org/doi/full/10.1056/NEJMsa0909994
Strickland BB, Jones JR, Ghandour RM, Kogan MD,
Newacheck PW. The medical home: health care access and
impact for children and youth in the United States. Pediatrics.
2011 Apr;127(4):604-11.

64

B.

Title V MCH Services Block Grant
National Performance Measures
No. National Performance Measure
1

Percent of women, ages 14 through 44, with a preventive medical visit in the past year

2

Percent of cesarean deliveries among low-risk first births

3

Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+
Neonatal Intensive Care Unit (NICU)
A) Percent of infants who are ever breastfed and B) Percent of infants breastfed
exclusively through 6 months
A) Percent of infants placed to sleep on their backs, B) Percent of infants placed to sleep
on a separate approved sleep surface, C) Percent of infants placed to sleep without soft
objects or loose bedding
Percent of children, ages 9 through 35 months, who received a developmental screening
using a parent-completed screening tool in the past year
7.1 Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9; and
7.2 Rate of hospitalization for non-fatal injury per 100,000 adolescents, ages 10 through 19
8.1 Percent of children, ages 6 through 11, who are physically active at least 60 minutes
per day; and
8.2 Percent of adolescents, ages 12 through 17, who are physically active at least 60
minutes per day
Percent of adolescents, ages 12 through 17, who are bullied or who bully others

4
5

6
7
8

9
10
11
12
13

14

15

Percent of adolescents, ages 12 through 17, with a preventive medical visit in the past
year
Percent of children with and without special health care needs, ages 0 through 17, who
have a medical home
Percent of adolescents with and without special health care needs, ages 12 through 17,
who received services necessary to make transitions to adult health care
13.1 Percent of women who had a dental visit during pregnancy; and
13.2 Percent of children, ages 1 through 17, who had a preventive dental visit in the past
year
14.1 Percent of women who smoke during pregnancy; and
14.2 Percent of children, ages 0 through 17, who live in households where someone
smokes
Percent of children, ages 0 through 17, who are continuously and adequately insured

65

PERFORMANCE MEASURE 1

Percent of women, ages 18 through 44, with a
preventive medical visit in the past year

GOAL

To increase the percent of women who have an annual
preventive medical visit.

DEFINITION

Numerator:
Number of women, ages 18 through 44, who had a preventive
medical visit in the past year
Denominator:
Number of women, ages 18 through 44
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH)
Developmental Objective 16.1: Increase the percentage of
women delivering a live birth who discussed preconception
health with a health care worker prior to pregnancy
Related to Access to Health Services (AHS) Developmental
Objective 7.0: Increase the proportion of persons who receive
appropriate clinical preventive services

DATA SOURCES and DATA
ISSUES

Behavioral Risk Factor Surveillance System (BRFSS)

MCH POPULATION DOMAIN

Women/Maternal Health

SIGNIFICANCE

A well-woman or preconception visit provides a critical
opportunity to receive recommended clinical preventive
services, including screening, counseling, and immunizations,
which can lead to appropriate identification, treatment, and
prevention of disease to optimize the health of women before,
between, and beyond potential pregnancies. For example,
screening and management of chronic conditions such as
diabetes, and counseling to achieve a healthy weight and
smoking cessation, can be advanced within a well woman visit
to promote women’s health prior to and between pregnancies
and improve subsequent maternal and perinatal outcomes.
The annual well-woman visit is recommended by the American
College of Obstetrics and Gynecologists (ACOG).
http://www.acog.org/Resources-And-Publications/CommitteeOpinions/Committee-on-Gynecologic-Practice/Well-WomanVisit

66

PERFORMANCE MEASURE 2

Percent of cesarean deliveries among low-risk
first births

GOAL

To reduce the percent of cesarean deliveries among low-risk
first births.

DEFINITION

Numerator:
Number of cesarean delivery among term (37+ weeks),
singleton, vertex births to nulliparous women
Denominator:
Number of term (37+ weeks), singleton, vertex births to
nulliparous women
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
7.1. Reduce cesarean births among low-risk women with no
prior cesarean (Baseline: 26.5%, Target: 23.9%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

MCH POPULATION DOMAIN

Women/Maternal Health

SIGNIFICANCE

Cesarean delivery can be a life-saving procedure for certain
medical indications. However, for most low-risk pregnancies,
cesarean delivery poses avoidable maternal risks of morbidity
and mortality, including hemorrhage, infection, and blood
clots—risks that compound with subsequent cesarean
deliveries. Much of the temporal increase in cesarean delivery
(over 50% in the past decade), and wide variation across
states, hospitals, and practitioners, can be attributed to firstbirth cesareans. Moreover, cesarean delivery in low-risk first
births may be most amenable to intervention through quality
improvement efforts. This low-risk cesarean measure, also
known as nulliparous term singleton vertex (NTSV) cesarean,
is endorsed by the American College of Obstetrician’s and
Gynecologists (ACOG), The Joint Commission (PC-02),
National Quality Forum (#0471), Center for Medicaid and
Medicare Services (CMS) – CHIPRA Child Core Set of
Maternity Measures, and the American Medical AssociationPhysician Consortium for Patient Improvement.
http://www.acog.org/Resources-And-Publications/Obstetric-CareConsensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery

67

PERFORMANCE MEASURE 3

Percent of very low birth weight (VLBW) infants
born in a hospital with a Level III+ Neonatal
Intensive Care Unit (NICU)

GOAL

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

DEFINITION

Numerator:
Number of VLBW infants born in a hospital with a level III or
higher NICU
Denominator:
Number of VLBW infants (< 1500 grams)
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
33: Increase the proportion of VLBW infants born at level III
hospitals or subspecialty perinatal centers (Baseline: 75%,
Target: 83.7%)

DATA SOURCES and DATA
ISSUES

Linked birth certificate and hospital data on NICU levels from
American Academy of Pediatrics (AAP)

MCH POPULATION DOMAIN

Perinatal/Infant Health

SIGNIFICANCE

Very low birth weight infants (<1,500 grams or 3.25 pounds)
are the most fragile newborns. Although they represented less
than 2% of all births in 2010, VLBW infants accounted for 53%
of all infant deaths, with a risk of death over 100 times higher
than that of normal birth weight infants (≥2,500 grams or 5.5
pounds). VLBW infants are significantly more likely to survive
and thrive when born in a facility with a level-III Neonatal
Intensive Care Unit (NICU), a subspecialty facility equipped to
handle high-risk neonates. In 2012, the AAP provided updated
guidelines on the definitions of neonatal levels of care to
include Level I (basic care), Level II (specialty care), and
Levels III and IV (subspecialty intensive care) based on the
availability of appropriate personnel, physical space,
equipment, and organization. Given overwhelming evidence of
improved outcomes, the AAP recommends that VLBW and/or
very preterm infants (<32 weeks’ gestation) be born in only
level III or IV facilities.
American Academy of Pediatrics Committee on Fetus And
Newborn. Levels of neonatal care. Pediatrics. 2012
Sep;130(3):587-97.
http://pediatrics.aappublications.org/content/130/3/587

68

PERFORMANCE MEASURE 4

A) Percent of infants who are ever breastfed
and
B) Percent of infants breastfed exclusively
through 6 months

GOAL

To increase the percent of infants who are breastfed and who are
breastfed exclusively through six months

DEFINITION

Numerator:
A) Number of infants who were ever breastfed
B) Number of infants breastfed exclusively through 6 months
Denominator:
A) Number of infants born in a calendar year
B) Number of infants born in a calendar year
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH) Objective
21.1: Increase the proportion of children who are ever breastfed
(Baseline: 74% in 2006, Target: 81.9%)
Related to Maternal, Infant, and Child Health (MICH) Objective
21.5: Increase the proportion of children who are breastfed
exclusively at (Baseline: 14.1% in 2006, Target: 25.5%)

DATA SOURCES and DATA
ISSUES

A) National Immunization Survey (NIS)
B) National Immunization Survey (NIS)

MCH POPULATION DOMAIN

Perinatal/Infant Health

SIGNIFICANCE

The American Academy of Pediatrics (AAP) recommends all
infants (including premature and sick newborns) exclusively
breastfeed for about six months as human milk supports optimal
growth and development by providing all required nutrients during
that time. Breastfeeding strengthens the immune system, reduces
respiratory infections, gastrointestinal illness, and SIDS, and
promotes neurodevelopment. Breastfed children may also be less
likely to develop diabetes, childhood obesity, and asthma.
Maternal benefits include reduced postpartum blood loss due to
oxytocin release and possible protective effects against breast
and ovarian cancer.
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding
and the use of human milk. Pediatrics. 2012 Mar;129(3):e827-41.
http://pediatrics.aappublications.org/content/early/2012/02/22/peds.20113552

69

PERFORMANCE MEASURE 5

A) Percent of infants placed to sleep on their
backs
B) Percent of infants placed to sleep on a
separate approved sleep surface
C) Percent of infants placed to sleep without
soft objects or loose bedding

GOAL

To increase the percent of infants placed to sleep on their
backs, on a separate approved sleep surface, without soft
objects or loose bedding

DEFINITION

Numerator:
A) Number of mothers reporting that they most often place
their baby to sleep on their back only
B) Number of mothers reporting that their baby always or often
sleeps alone, usually in a crib, bassinet, or pack and play,
and not usually in a standard bed, couch, sofa, armchair,
car seat, or swing
C) Number of mothers reporting that their baby does not
usually sleep with blankets, toys, cushions, pillows, or crib
bumper pads
Denominator:
A) Number of live births
B) Number of live births
C) Number of live births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
20: Increase the proportion of infants placed to sleep on their
backs (Baseline: 69.0%, Target: 75.9%)

DATA SOURCES and DATA
ISSUES

Pregnancy Risk Assessment Monitoring System (PRAMS)

MCH POPULATION DOMAIN

Perinatal/Infant Health

SIGNIFICANCE

Sleep-related infant deaths, also called Sudden Unexpected
Infant Deaths (SUID), are the leading cause of infant death after
the first month of life and the third leading cause of infant death
overall. Sleep-related SUIDs include Sudden Infant Death
Syndrome (SIDS), unknown cause, and accidental suffocation
and strangulation in bed. Due to heightened risk of SIDS when
infants are placed to sleep in side (lateral) or stomach (prone)
sleep positions, the American Academy of Pediatrics (AAP) has
long recommended the back (supine) sleep position. In 2011,
AAP expanded its recommendations to help reduce the risk of
all sleep-related deaths through a safe sleep environment that
includes use of the back-sleep position, on a separate firm
sleep surface (room-sharing without bed sharing), and without
loose bedding.
http://pediatrics.aappublications.org/content/128/5/1030

70

PERFORMANCE MEASURE 6 Percent of children, ages 9 through 35 months,
who received a developmental screening using a
parent-completed screening tool in the past year
GOAL

To increase the percent of children who receive a
developmental screening.

DEFINITION

Numerator:
Number of children, ages 9 through 35 months (2 years), whose
parents completed a Standardized Developmental Screening
tool in the past year
Denominator:
Number of children, ages 9 through 35 months
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
29-1: Increase the proportion of children (aged 10-35 months)
who have been screened for an Autism Spectrum Disorder and
other developmental delays. (Baseline: 22.6%, Target: 24.9%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Child Health

SIGNIFICANCE

Early identification of developmental disorders is critical to the
well-being of children and their families. It is an integral function
of the primary care medical home. The percent of children with
a developmental disorder has been increasing, yet overall
screening rates have remained low. The American Academy of
Pediatrics (AAP) recommends screening tests begin at the nine
month visit. The developmental screening measure is
endorsed by the National Quality Forum and is part of the Core
Set of Children’s Health Care Quality Measures for Medicaid
and CHIP.
Council on Children With Disabilities; Section on Developmental
Behavioral Pediatrics; Bright Futures Steering Committee;
Medical Home Initiatives for Children With Special Needs
Project Advisory Committee. Identifying infants and young
children with developmental disorders in the medical home: an
algorithm for developmental surveillance and screening.
Pediatrics. 2006 Jul;118(1):405-20.
http://pediatrics.aappublications.org/content/118/1/405

71

PERFORMANCE MEASURE 7 7.1 Rate of hospitalization for non-fatal injury
per 100,000 children, ages 0 through 9
7.2 Rate of hospitalization for non-fatal injury
per 100,000 adolescents, ages 10 through 19
GOAL

To decrease the rate of hospital admissions for non-fatal injury
among children ages 0 through 19.

DEFINITION

Numerator:
7.1 Number of hospital admissions with a primary diagnosis of
unintentional or intentional injury among children ages 0
through 9 (excludes in-hospital deaths)
7.2 Number of hospital admissions with a primary diagnosis of
unintentional or intentional injury among adolescents, ages
10 through 19 (excludes in-hospital deaths)
Denominator:
7.1 Number of children, ages 0 through 9
7.2 Number of adolescents, ages 10 through19
Units: 100,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 1.2:
Reduce hospitalizations for nonfatal injuries. (Baseline: 617.6
per 100,000. Target: 555.8 per 100,000.)

DATA SOURCES and DATA
ISSUES

Healthcare Cost and Utilization Project (HCUP) - State Inpatient
Database (SID)
Population estimates come from the U.S. Census Bureau

MCH POPULATION DOMAIN

Child Health and/or Adolescent Health

SIGNIFICANCE

Unintential injury is the leading cause of child and adolescent
mortality, from age 1 through 19. Homicide and suicide, violent
or intentional injury, are the second and third leading causes of
death for adolescents ages 15 through 19. For those who
suffer non-fatal severe injuries, many will become children with
special health care needs. Effective interventions to reduce
injury exist but are not fully implemented in systems of care that
serve children and their families. Reducing the burden of
nonfatal injury can greatly improve the life course trajectory of
infants, children, and adolescents resulting in improved quality
of life and cost savings.
Heron M. Deaths: Leading Causes for 2014. National Vital
Statistics Reports. 2016 June 30. 65(5).
https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_05.pdf
CDC. VitalSigns: Child Injury. April 2012.
https://www.cdc.gov/vitalsigns/childinjury/
CDC. National Action Plan for Injury Prevention. April 2012.
https://www.cdc.gov/safechild/nap/index.html

72

PERFORMANCE MEASURE 8 8.1 Percent of children, ages 6 through 11, who
are physically active at least 60 minutes per day
8.2 Percent of adolescents, ages 12 through 17
who are physically active at least 60 minutes per
day
GOAL

To increase the percent of children and adolescents who are
physically active.

DEFINITION

Numerator:
8.1 Number of children, ages 6 through 11, who are reported
by their parents to be physically active at least 60 minutes
per day in the past week (NSCH)
8.2 Number of adolescents, ages 12 through 17, who are
reported by their parents to be physically active at least 60
minutes per day in the past week (NSCH)
Number of adolescents in grades 9 through 12 who report
being physically active at least 60 minutes per day in the
past week (YRBSS)
Denominator:
8.1 Number of children ages 6 through 11 (NSCH)
8.2 Number of adolescents ages 12 through 17 (NSCH)
Number of adolescents in grades 9 through 12 (YRBSS)
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Physical Activity (PA) Objective 4.1: Increase the
proportion of the Nation’s public and private elementary
schools that require daily physical education for all students.
(Baseline: 3.8%, Target: 4.2%)
Related to Physical Activity (PA) Objective 3: Increase the
proportion of adolescents who meet current Federal physical
activity guidelines for aerobic physical activity and for musclestrengthening activity. (Baseline: 18.4%, Target: 20.2% for
adolescents to meet current physical activity guidelines for
aerobic physical activity)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)
Youth Risk Behavior Surveillance System (YRBSS)

MCH POPULATION DOMAIN

Child Health and/or Adolescent Health

SIGNIFICANCE

Regular physical activity can improve the health and quality of
life of Americans of all ages, regardless of the presence of a
chronic disease or disability. Physical activity in children and
adolescents reduces the risk of early life risk factors for
cardiovascular disease, hypertension, Type II diabetes, and
osteoporosis. In addition to aerobic and muscle-strengthening
activities, bone-strengthening activities are especially important
for children and young adolescents because the majority of
peak bone mass is obtained by the end of adolescence.

73

U.S. Department of Health and Human Services. 2008 Physical
Activity Guidelines for Americans
https://health.gov/paguidelines/guidelines/

74

PERFORMANCE MEASURE 9 Percent of adolescents, ages 12 through 17,
who are bullied or who bully others
GOAL

To reduce the percent of adolescents who are bullied or who
bully others.

DEFINITION

Numerator:
Number of adolescents in grades 9 through 12 who report that
they are bullied on school property or electronically in the past
year (YRBSS)
Number of adolescents ages 12 through 17 who are reported
by a parent/guardian to be bullied (NSCH)
Number of adolescents ages 12 through 17 who are reported
by a parent/guardian to bully others (NSCH)
Denominator:
Number of adolescents in grades 9 through 12 (YRBSS)
Number of adolescents ages 12 through 17 (NSCH)

Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 35:
Reduce bullying among adolescents. (Baseline: 19.9%,
Target: 17.9%)

DATA SOURCES and DATA
ISSUES

Youth Risk Behavior Surveillance System (YRBSS)
National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Adolescent Health

SIGNIFICANCE

Bullying, particularly among school-age children, is a major
public health problem. Estimates suggest nearly 30% of
American adolescents reported at least moderate bullying
experiences as the bully, the victim, or both. Bullying
experiences are associated with a number of behavioral,
emotional, and physical adjustment problems. Adolescents
who bully others tend to exhibit other defiant and delinquent
behaviors, have poor school performance, be more likely to
drop-out of school, and are more likely to bring weapons to
school. Victims of bullying tend to report feelings of
depression, anxiety, low self-esteem, and isolation; poor
school performance; suicidal ideation; and suicide attempts.
Bullying victims who also perpetrate bullying (i.e., bully-victims)
may exhibit the poorest functioning, in comparison with either
victims or bullies. Emotional and behavioral problems
experienced by victims, bullies, and bully-victims may continue
into adulthood and produce long-term negative outcomes,
including low self-esteem and self-worth, depression, antisocial
behavior, vandalism, drug use and abuse, criminal behavior,
gang membership, and suicidal ideation.
www.stopbullying.gov

75

PERFORMANCE MEASURE
10

Percent of adolescents, ages 12 through 17,
with a preventive medical visit in the past year

GOAL

To increase the percent of adolescents who have a preventive
medical visit.

DEFINITION

Numerator:
Number of adolescents, ages 12 through 17, with a preventive
medical visit in the past year
Denominator:
Number of adolescents, ages 12 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Adolescent Health (AH) Objective 1: Increase the
proportion of adolescents who have had a wellness checkup in
the past 12 months. (Baseline: 68.7%, Target: 75.6%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Adolescent Health

SIGNIFICANCE

Adolescence is a period of major physical, psychological, and
social development. As adolescents move from childhood to
adulthood, they assume individual responsibility for health
habits, and those who have chronic health problems take on a
greater role in managing those conditions. Initiation of risky
behaviors, such as unsafe sexual activity, unsafe driving, and
substance use, is a critical health issue during adolescence,
as adolescents try on adult roles and behaviors. An annual
preventive well visit may help adolescents adopt or maintain
healthy habits and behaviors, avoid health‐damaging
behaviors, manage chronic conditions, and prevent disease.
The Bright Futures guidelines recommends that adolescents
have an annual checkup from age 11 through 21. The visit
should cover a comprehensive set of preventive services, such
as a physical examination, immunizations, and discussion of
health‐related behaviors including healthy eating, physical
activity, substance use, sexual behavior, violence, and motor
vehicle safety. The adolescent well-care visit measure for
health plans is part of the core measure sets for Medicaid and
the National Committee for Quality Assurance.
National Adolescent and Young Adult Health Information Center
(2016). Summary of Recommended Guidelines for Clinical Preventive
Services for Adolescents up to age 18.
http://nahic.ucsf.edu/adolescent-guidelines

76

PERFORMANCE MEASURE
11

Percent of children with and without special
health care needs, ages 0 through 17, who have
a medical home

GOAL

To increase the percent of children with and without special
health care needs who have a medical home

DEFINITION

Numerator:
Number of children with and without special health care needs,
ages 0 through 17, who meet the criteria for having a medical
home (personal doctor or nurse, usual source for care, and
family-centered care; referrals or care coordination if needed)
Denominator:
Number of children, ages 0 through 17
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Identical to Maternal, Infant, and Child Health (MICH)
Objectives 30.1: Increase the proportion of children who have
access to a medical home, (Baseline: 57.5%, Target: 63.3%)
and 30.2: Increase the proportion of children with special
health care needs who have access to a medical home.
(Baseline: 49.8%, Target: 54.8%)
Related to Objective Maternal, Infant, and Child Health (MICH)
Objective 31: Increase the proportion of children with special
health care needs who receive their care in family-centered,
comprehensive, coordinated systems. (Baseline: 20.4% for
children aged 0-11, Target: 22.4%; Baseline: 13.8% for
children aged 12 through 17, Target 15.2%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Children with Special Health Care Needs or All Children
(CSHCN and non-CSHCN)

SIGNIFICANCE

The American Academy of Pediatrics (AAP) specifies seven
qualities essential to medical home care, which include
accessible, family-centered, continuous, comprehensive,
coordinated, compassionate and culturally effective. Providing
comprehensive and coordinated care to children in a medical
home is the standard of pediatric practice. Research indicates
that children with a stable and continuous source of health care
are more likely to receive appropriate preventive care, are less
likely to be hospitalized for preventable conditions, and are
more likely to be diagnosed early for chronic or disabling
conditions. The Maternal and Child Health Bureau uses the
AAP definition of medical home.
www.medicalhomeinfo.aap.org

77

PERFORMANCE MEASURE
12

Percent of adolescents with and without special
health care needs, ages 12 through 17, who
received services necessary to make transitions
to adult health care

GOAL

To increase the percent of adolescents with and without special
health care needs who have received the services necessary to
make transitions to adult health care.

DEFINITION

Numerator:
Number of adolescents with and without special health care
needs, ages 12 through 17, whose families report that they
received the services necessary to transition to adult health care
Denominator:
Number of adolescents, ages 12 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

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

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Children with Special Health Care Needs or All Adolescents
(CSHCN and non-CSHCN)

SIGNIFICANCE

The transition of youth to adulthood, including the movement
from a child to an adult model of healthcare, has become a
priority issue nationwide as evidenced by the 2011 clinical
report and algorithm developed jointly by the AAP, American
Academy of Family Physicians and American College of
Physicians to improve healthcare transitions for all youth and
families. Poor health has the potential to impact negatively the
youth and young adults’ academic and vocational outcomes.
Over 90 percent of children with special health care needs now
live to adulthood, but are less likely than their non-disabled
peers to complete high school, attend college or to be
employed. Health and health care are cited as two of the major
barriers to making successful transitions.
American Academy of Pediatrics; American Academy of Family
Physicians; American College of Physicians-American Society of
Internal Medicine. A consensus statement on health care transitions for
young adults with special health care needs. Pediatrics. 2002
Dec;110(6 Pt 2):1304-6.
http://pediatrics.aappublications.org/content/110/Supplement_3/1304

78

PERFORMANCE MEASURE
13

13.1 Percent of women who had a preventive
dental visit during pregnancy
13.2 Percent of children, ages 1 through 17, who
had a preventive dental visit in the past year

GOAL

13.1 To increase the number of pregnant women who have a
dental visit during pregnancy and
13.2 To increase the number of children, ages 1 through 17,
who had a preventive dental visit in the past year.

DEFINITION

Numerator:
13.1 Number of women who had a preventive dental visit
during pregnancy
13.2 Number of infant or child, ages 1 through 17, who had a
preventive dental visit in the past year
Denominator:
13.1 Number of live births
13.2 Number of children, ages 1 through 17
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Oral Health (OH) Objective 7. Increase the
proportion of children, adolescents, and adults who used the
oral health care system in the past year. (Baseline: 44.5%,
Target: 49.0%)
Related to Oral Health (OH) Objective 8. Increase the
proportion of low-income children and adolescents who receive
any preventive dental service during the past year. (Baseline:
30.2%, Target: 33.2%)

DATA SOURCES and DATA
ISSUES

13.1 Pregnancy Risk Assessment Monitoring System (PRAMS)
13.2 National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Women/Maternal Health, Child Health, and/or Adolescent Heath

SIGNIFICANCE

Oral health is a vital component of overall health and oral health
care remains the greatest unmet health need for children.
Insufficient access to oral health care and effective preventive
services affects children’s health, education, and ability to
prosper. To prevent tooth decay and oral infection, the
American Academy of Pediatric Dentistry (AAPD) recommends
preventive dental care for all children after the eruption of the
first tooth or by 12 months of age, usually at intervals of every 6
months. Preventive dental care in pregnancy is also
recommended by the American College of Obstetricians and
Gynecologists (ACOG) to improve lifelong oral hygiene habits
and dietary behavior for women and their families.
https://www.mchoralhealth.org/materials/consensus_statement.php
http://www.aapd.org/media/Policies_Guidelines/G_Periodicity7.pdf

79

PERFORMANCE MEASURE
14

14.1 Percent of women who smoke during
pregnancy and
14.2 Percent of children, ages 0 through 17, who
live in households where someone smokes

GOAL

14.1 To decrease the number of women who smoke during
pregnancy and
14.2 To decrease the number of households where someone
smokes.

DEFINITION

Numerator:
14.1 Number of women who report smoking during pregnancy
14.2 Number of children, ages 0 through 17, who live in
households where there is household member who
smokes
Denominator:
14.1 Number of live births
14.2 Number of children, ages 0 through 17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Tobacco Use (TU) Objective 6: Increase smoking
cessation during pregnancy (Target: 30.0%) and related to
Tobacco Use (TU) Objective 11.1: Reduce the proportion of
children aged 3 to 11 years exposed to secondhand smoke.
(Baseline: 52.2% , Target 47%)

DATA SOURCES and DATA
ISSUES

14.1 National Vital Statistics System (NVSS)
14.2 National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Women/Maternal Health, Child Health, and/or Adolescent
Health

SIGNIFICANCE

Women who smoke during pregnancy are more likely to
experience a fetal death or deliver a low birth weight baby.
Adverse effects of parental smoking on children have been a
clinical and public health concern for decades. Children have
an increased frequency of ear infections; acute respiratory
illnesses and related hospital admissions during infancy;
severe asthma and asthma-related problems; lower respiratory
tract infections; and SIDS.
The Health Consequences of Smoking—50 Years of Progress. A
Report of the Surgeon General. Atlanta, Georgia: U.S. Department of
Health and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health, 2014.
https://www.surgeongeneral.gov/library/reports/50-years-ofprogress/index.html

80

PERFORMANCE MEASURE
15

Percent of children, ages 0 through 17, who are
continuously and adequately insured

GOAL

To increase the percent of children who are adequately insured

DEFINITION

Numerator:
Number of children, ages 0 through 17, who were reported to
be continuously insured in the past year with adequate
coverage, based on 3 criteria: whether their children’s
insurance covers needed services and providers, and
reasonably covers costs. If a parent answered “always” or
“usually” to all three dimensions of adequacy, then the child
was considered to have adequate insurance coverage. (No
out-of-pocket costs were considered to be “always”
reasonable.)
Denominator:
Number of children, ages 0 through 17
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Access to Health Services (AHS) Objective 1:
Increase the proportion of persons with health insurance
Related to Access to Health Services (AHS) Objective 6:
Reduce the proportion of persons who are unable to obtain or
delay in obtaining necessary medical care, dental care, or
prescription medicines

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Child Health, Adolescent Health, and/or Children with Special
Health Care Needs

SIGNIFICANCE

Almost one-quarter of American children with continuous
insurance coverage are not adequately insured. Inadequately
insured children are more likely to have delayed or forgone
care, lack a medical home, be less likely to receive needed
referrals and care coordination, and receive family-centered
care. The American Academy of Pediatrics (AAP) highlighted
the importance of this issue with a policy statement. The major
problems cited were cost-sharing requirements that are too
high, benefit limitations, and inadequate coverage of needed
services.
Kogan MD, Newacheck PW, Blumberg SJ, Ghandour RM,
Singh GK, Strickland BB, van Dyck PC. Underinsurance among
children in the United States. N Engl J Med. 2010Aug
26;363(9):841-51.
http://www.nejm.org/doi/full/10.1056/NEJMsa0909994

81

APPENDIX D: FAMILY PARTNERSHIP CONTINUUM

Family partnership is defined as patients, families, their representatives, and health
professionals working in active partnership at various levels across the health care system—
direct care, organizational design and governance, and policy making—to improve health and
health care. This partnership is accomplished through the intentional practice of working with
families for the ultimate goal of positive outcomes in all areas through the life course.5 The
Figure below represents a continuum of engagement with families and individuals at different
levels in the health care system, from the consultation, involvement, and partnership stage. 6

A Multidimensional Framework for Patient and Family Engagement in Health and Health Care

Continuum of Engagement
Levels of
Engagement

Consultation

Involvement

Partnership and
Shared Leadership

Direct Care

Patient receive
information
about a
diagnosis

Patients are asked
about their
preferences in
treatment plan

Treatment decisions
are made based on
patients’
preferences, medical
evidence, and
clinical judgement

Organizational
Design and
Governance

Organization
surveys patients
about their care
experiences

Hospital involves
patients as
advisers or
advisory council
members

Patients co-lead
hospital safety and
quality
improvement
committees

Policy Making

Public agency
conducts focus
groups with
patients to ask
opinions about a
health care issue

Patients’
recommendations
about research
priorities are used
by public agency
to make funding
decisions

Patients have equal
representation on
agency committee
that makes decisions
about how to
allocate resources to
health programs

Factors influencing engagement:
• Patient (beliefs about the patient role, health literacy, education)
• Organization (policies and practices, culture)
• Society (social norms, regulations, policy)
5

Carman K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtcl, C., Sweeney, J. Patient and Family
Engagement: A framework for understanding the elements and developing interventions and policies.
Health Affairs. 2013; 32:223-231
6
Ibid.

82

APPENDIX E:

NEEDS ASSESSMENT − BACKGROUND AND
CONCEPTUAL FRAMEWORK

Conducting a Needs Assessment is a systematic process to acquire an accurate, thorough
picture of the strengths and weaknesses of a state’s public health system that can be used in
response to the preventive and primary care services needs for ALL pregnant women, mothers,
infants (up to age one), and children, including children with special health care needs [Section
505 (a)(1)]. The Needs Assessment process includes the collection and examination of
information about the state’s capacity and infrastructure, needs and desired outcomes for the
MCH population, and legislative mandates, etc. This information is utilized to determine
priority goals, develop a plan of action, and to allocate funds and resources. The Needs
Assessment is a collaborative process that should include the HRSA/MCHB, the state
Department of Health, families, practitioners, the community, and other agencies and
organizations within each state and jurisdiction that have an interest in the well-being of the
MCH population.
Title V of the Social Security Act requires states to conduct a statewide Needs Assessment
every five years. States will report on the next Five-year Needs Assessment in calendar year
2020 as part of the FY 2021 MCH Block Grant Application process. Rather than submitting a
comprehensive “stand-alone document”, as was required prior to 2015, states now submit a
Five-year Needs Assessment Summary that concisely describes the process and findings. As the
Needs Assessment document may serve multiple purposes, a state may wish to develop a
more comprehensive document to meets its broader needs. This document cannot be
submitted in place of the required Five-year Needs Assessment Summary, but states may
include a URL, if the document is posted online, in the Five-year Needs Assessment Summary
or they may submit the document as an attachment to the Application/Annual Report in the
electronic application system. Over the five-year reporting period, states are encouraged to
continuously revisit the Five-Year Needs Assessment Summary and to provide updates, as
needed, in the interim year Applications/Annual Reports. Furthermore, it is expected that
states will have ongoing communication with stakeholders and partners throughout the
Needs Assessment process and continue to engage with such partners during the interim
reporting years.
The primary goal of the statewide Needs Assessment is to improve MCH outcomes and to
strengthen its state, local and community partnerships for addressing the needs of its MCH
population. The following figure illustrates the continuity of the Needs Assessment process and
its relationship to the planning and monitoring functions of Title V and the population that it
serves.

83

State MCH Block Grant Needs Assessment, Planning, Implementation and
Monitoring Process

A brief description of the steps involved in the Public Health Planning Cycle to inform ongoing
needs assessment is presented in the following sections.
1. Engage Stakeholders
As depicted, the starting point for the Needs Assessment process is to engage
stakeholders. Engaging stakeholders and strengthening partnerships is a continuous
and on-going activity. The state needs strong partnerships with its stakeholders
throughout the Needs Assessment process. Effective coalitions can help the state to
realistically assess needs and identify desired outcomes and mandates, assess
strengths and examine capacity, select priorities, seek resources, set performance

84

objectives, develop an action plan, allocate resources, and monitor progress for
impact on targeted outcomes.
2. Assess Needs and Identify Desired Outcomes and Mandates
The second stage in the process is to assess needs of the MCH population groups
using the Title V National Outcome Measures (NOMs), national, state and strategy
performance measures and other available state-level quantitative and qualitative
data. States should assess MCH population needs based on the following five
population health domains: 1) Women/Maternal Health; 2) Perinatal/Infant Health;
3) Child Health; 4) Adolescent Health; and 5) Children with Special Health Care Needs
(CSHCN). These population health domains fall with the three MCH population groups
that are defined in Section 505(a)(1) of the Title V legislation. The anticipated
outcome of this assessment is to identify community/system needs and desired
outcomes by specific MCH population groups. In addition, the state will need to
identify needs and desired outcomes for cross-cutting and systems issues. The state
will also need to identify legislative, political, community-driven, financial, and/or
other internal and external mandates which may go beyond the findings identified
through the Needs Assessment process but are priorities for implementation within
the state.
3. Examine Strengths and Capacity
The third stage in the Needs Assessment process is examining strengths and capacity.
This stage involves examining the state’s capacity to engage in various activities,
including conducting the statewide Five-year Needs Assessment and
collecting/reporting annual performance data based on the five identified MCH
population health domains and the types of MCH services provided.
This stage involves describing and assessing the state’s current resources, activities,
and services as well as the state’s ability to continue to provide quality services by
each of the three MCH service levels. These levels include 1) Direct Services;
2) Enabling Services; and 3) Public Health Services and Systems. The anticipated
outcome is a better understanding of the relationship of the state’s existing
program/system capacity to its identified strengths and needs. This examination may
reveal strengths and weaknesses in capacity not previously identified.
4. Select Priorities
In the select priorities stage, each state examines the identified needs and matches
them to the desired outcomes, required mandates and level of existing capacity. As a
result, states will select seven to ten priority areas for targeted focus in promoting
continued improvement and progress. Examples of inputs include: the Needs
85

Assessment process, the opinions of stakeholders, the examination of program
capacity and the political priorities within the state. The anticipated outcome is the
development of a set of priority needs (between seven and ten), which are unique to
the individual state based on its Needs Assessment findings. Priorities identified
should address areas in which the state believes there is reasonable opportunity for a
focused programmatic effort (e.g., new or enhanced interventions, initiatives, or
systems of care) to lead to an improved outcome.
5. Set Performance Objectives
Setting performance objectives consists of two phases. In the first phase, each state
will develop action strategies to address their identified priority needs. Based on the
priority needs and program strategies developed, the state will select five National
Performance Measures (NPMs), Evidence-based or –informed Strategy Measures
(ESMs) for addressing each of the selected NPMs and State Performance Measures
(SPMs). SPMs should be based on the state’s identified MCH priorities and target
those priority needs that are not fully addressed by the selected NPMs and their
related ESMs.
Secondly, the state will set five-year targets (i.e., performance objectives) for the five
selected NPMs, the ESMs and the SPMs. The anticipated results of this stage are the
identification of NOMs, NPMs, ESMs and SPMs that directly relate to the state
priorities and establish a level of accountability for achieving measureable progress.
6. Develop an Action Plan
The next stage is to develop an action plan, which involves the planning and
identification of specific activities for implementing the program strategies which
were developed in Stage 5 to address the identified priority needs and selected
national/state measures. In developing an Action Plan, states will create the Five-year
State Action Plan Table. As a planning tool, states will have flexibility in how they
format the Table provided that the information is organized around the five identified
population health domains. At a minimum, the Five-year State Action Plan Table
should include the relevant priority needs, key strategies and measures (i.e., NOMs,
NPMs, SPMs and ESMs) for each of the MCH health domains. Based on the identified
priorities, measures and strategies, the state will develop a five-year program plan
that includes specific activities for achieving the targeted outcomes and performance
specific to each health domain.
In developing the Action Plan, the state shall complete a Five-year State Action Plan
Table as part of the first year Application/Annual Report in the five year cycle. This
Table is a tool to assist states in aligning their program strategies, NPMs, SPMs and
ESMs with the priority needs that were identified in the Five-year Needs Assessment.
Updates to the strategies, activities and measures will be provided by the state, as
86

needed, in subsequent interim year Applications/Annual Reports. Figure 4 in
Part Two, Section II of the Application/Annual Report Guidance depicts the steps
involved in the development of, and the annual reporting on, the implementation of
the Five-year State Action Plan.
7. Seek and Allocate Resources
Following the identification of program activities is the allocation of resources stage.
In this stage, the focus is on the funding of planned activities to address state
priorities. Inputs include the five-year State Action Plan, current budgets, political
priorities, and partnerships. The anticipated outcome is the development of a
program budget and plan that directs available resources towards the activities
identified in Stage Six as the most important for addressing the state's priorities.
8. Monitor Progress for Impact on Outcomes
In monitoring progress for impact on outcomes, the states examine the results of
their efforts to see if there has been improvement. Inputs include NOMs, NPMs, SPMs
and ESMs, performance objectives and other quantitative and qualitative information.
Potential outcomes may include altered activities and shifting of resource allocations
to address current levels of performance and availability of resources. Feedback loops
between various stages of the process allow for continuous input and re-evaluation of
the outputs.
9. Report Back to Stakeholders
This final step assures accountability to the stakeholders and partners who have
worked with the MCH staff throughout the Needs Assessment process. It also assures
the continued involvement of all stakeholders and partners in the ongoing Needs
Assessment processes.

87

APPENDIX F: ASSURANCES AND CERTIFICATIONS
View Burden Statement

OMB Number: 4040-0007
Expiration Date: 06130/2014

ASSURANCES - NON-CONSTRUCTION PROGRAMS

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND
IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE:

Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances.
If such is the case, you will be notified.

As the duly authorized representative of the applicant, I certify that the applicant:
1.

Has the legal authority to apply for Federal assistance
and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project cost) to ensure proper planning, management
and completion of the project described in this
application.

2.

Will give the awarding agency, the Comptroller General
of the United States and, if appropriate, the State,
through any authorized representative, access to and
the right to examine all records, books, papers, or
documents related to the award; and will establish a
proper accounting system in accordance with generally
accepted accounting standards or agency directives.

3.

Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.

4.

Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding
agency.

5.

Will comply with the Intergovernmental Personnel Act of
1970 (42 U.S.C. §§4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C.F.R. 900, Subpart F).

6.

Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C.§§16811683, and 1685-1686), which prohibits discrimination on
the basis of sex; (c) Section 504 of the Rehabilitation

Act of 1973, as amended (29 U.S.C. §794), which
prohibits discrimination on the basis of handicaps; (d)
the Age Discrimination Act of 1975, as amended (42 U.
S.C. §§6101-6107), which prohibits discrimination on
the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) §§523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290
ee- 3), as amended, relating to confidentiality of alcohol
and drug abuse patient records; (h) Title VIII of the Civil
Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale,
rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and, U) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
7.

Will comply, or has already complied, with the
requirements of Titles II and Ill of the Uniform
Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (P.L. 91-646) which provide for
fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or
federally-assisted programs. These requirements
apply to all interests in real property acquired for
project purposes regardless of Federal participation in
purchases.

8. Will comply, as applicable, with provisions of the
Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328)
which limit the political activities of employees whose
principal employment activities are funded in whole
or in part with Federal funds.

Previous Edition Usable

Authorized for Local Reproduction

88

Standard Form 4248 (Rev. 7-97)
Prescribed by OMB Circular A-102

9. Will comply, as applicable, with the provisions of the Davis­
Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract
Work Hours and Safety Standards Act (40 U.S.C. §§327333), regarding labor standards for federally-assisted
construction subagreements.
10. Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires
recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000 or more.
11. Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of
Federal actions to State (Clean Air) Implementation Plans
under Section 176(c) of the Clean Air Act of 1955, as
amended (42 U.S.C. §§7401 etseq.); (g) protection of
underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended (P.L. 93-523);
and, (h) protection of endangered species under the
Endangered Species Act of 1973, as amended (P.L. 93205).
12. Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. §§1271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.

13. Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Actof1966, as amended (16 U.S.C. §470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of
1974 (16 U.S.C. §§469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of
human subjects involved in research, development, and
related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of
1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et
seq.) pertaining to the care, handling, and treatment of
warm blooded animals held for research, teaching, or
other activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. §§4801 et seq.) which
prohibits the use of lead-based paint in construction or
rehabilitation of residence structures.
17. Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act Amendments of 1996 and OMB Circular No. A-133,
"Audits of States, Local Governments, and Non-Profit
Organizations."
18. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
governing this program.
19. Will comply with the requirements of Section 106(g) of
the Trafficking Victims Protection Act (TVPA) of 2000, as
amended (22 U.S.C. 7104) which prohibits grant award
recipients or a sub-recipient from (1) Engaging in severe
forms of trafficking in persons during the period of time
that the award is in effect (2) Procuring a commercial
sex act during the period of time that the award is in
effect or (3) Using forced labor in the performance of the
award or subawards under the award.

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

TITLE

APPLICANT ORGANIZATION

DATE SUBMITTED
Standard Form 4248 (Rev. 7-97) Back

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HHS-5161-1 (08/2007)

CERTIFICATIONS

1. CERTIF1CATION REGARDING LOBBYING

OMB Approval No. 0990-0317

3. CERTIF1CATION REGARDING
ENVIRONMENTAL TOBACCO SMOKE

Title 31, United States Code, Section 1352, entitled
"Limitation on use of appropriated funds to influence
certain Federal contracting and financial transactions,"
generally prohibits recipients of Federal grants and
cooperative agreements from using Federal (appropriated)
funds for lobbying the Executive or Legislative Branches
of the Federal Government in connection with a
SPECIFIC grant or cooperative agreement. Section 1352
also requires that each person who requests or receives a
Federal grant or cooperative agreement must disclose
lobbying undertaken with non-Federal (non-appropriated)
funds. These requirements apply to grants and cooperative
agreements EXCEEDING $100,000 in total costs (45
CFR Part 93). By signing and submitting this application,
the applicant is providing certification set out in Appendix
A to 45 CFR Part 93.

2. CERTIF1CATION REGARDING PROGRAM FRAUD
CIVIL REMEDIES ACT (PFCRA)

The authorized official signing for the applicant
organization certifies that the statements herein are true,
complete, and accurate to the best of his or her
knowledge, and that he or she is aware that any false,
fictitious, or fraudulent statements or claims may subject
him or her to criminal, civil, or administrative penalties.
The official signing agrees that the applicant organization
will comply with the HHS terms and conditions of award
if a grant is awarded as a result of this application.

Public Law 103-227, also known as the Pro-Children
Act of 1994 (Act), requires that smoking not be
permitted in any portion of any indoor facility owned
or leased or contracted for by an entity and used
routinely or regularly for the provision of health, day
care, early childhood development services, education
or library services to children under the age of 18, if the
services are funded by Federal programs either directly
or through State or local governments, by Federal
grant, contract, loan, or loan guarantee. The law also
applies to children's services that are provided in
indoor facilities that are constructed, operated, or
maintained with such Federal funds. The law does not
apply to children's services provided in private
residence, portions of facilities used for inpatient drug
or alcohol treatment, service providers whose sole
source of applicable Federal funds is Medicare or
Medicaid, or facilities where WIC coupons are
redeemed.
Failure to comply with the provisions of the law may
result in the imposition of a civil monetary penalty of
up to $1,000 for each violation and/or the imposition of
an administrative compliance order on the responsible
entity.
The authorized official signing for the applicant
organization certifies that the applicant organization
will comply with the requirements of the Act and will
not allow smoking within any portion of any indoor
facility used for the provision of services for children
as defmed by the Act. The applicant organization
agrees that it will require that the language of this
certification be included in any sub-awards which
contain provisions for children's services and that all
sub-recipients shall certify accordingly.
HHS strongly encourages all grant recipients to provide
a smoke-free workplace and promote the non-use of
tobacco products. This is consistent with the HHS
mission to protect and advance the physical and mental
health of the American people.

HHS Certifications (08-2007)

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APPENDIX G:

Submission
Date
July 15, 2018

REQUIRED APPLICATION/ANNUAL REPORT COMPONENTS
AND TIMELINE
Application Year

Annual Report Year

Fiscal Year (FY) 2019
(Interim Year 04 Application of Five-year
Reporting Cycle.)

FY 2017
(Interim Year 02 of Previous Reporting Cycle)

 Complete SF-424
 Update Executive Summary
 Update Needs Assessment Summary
 Add FY 2023 Performance Objective for
each selected NPM, SPM, and ESM on
Form #10A
 Update State Action Plan as needed
 Complete Narrative Sections of
Application, including Presentation of the
State’s Five-year Action Plan by MCH
Health Domain
 Enter Budgeted Data for Application Year
on Forms #2, #3a and #3b
 Update Listed Names of MCH Director,
CSHSN Director and Family/Youth Leader
on Form #8

 Enter the FY 2017 Annual Indicator Data
(specifically, the Numerator, Denominator,
Data Source and Data Note) for the
Selected NPMs, ESMs and SPMs.
 Report on FY 2017 Program Activities and
Analyze Performance, by MCH Health
Domain, using New Narrative Format
 Enter Expenditure Data on Forms #2, #3a,
and #3b
 Enter Required Data (i.e., Newborn and
Others Screening, Unduplicated Count and
Total Encounters of Individuals Served,
Deliveries and Infants Served by Title V and
Entitled to Benefits Under Title XIX and
State Toll-free Hotline and Other
Appropriate Methods Data) on Forms #4,
#5a, #5b, #6 and #7 for the Reporting Year.

 Review Other State Data (OSD) on
Form #11 and Form #10A for National
Outcome Measures (NOMs)
July 15, 2019

FY 2020
(Interim Year 05 Application of Five-year
Reporting Cycle)
 Complete SF-424
 Update Executive Summary
 Update Needs Assessment Summary
 Add FY 2024 Performance Objective for
each selected NPM, SPM, and ESM on
Form #10A
 Update State Action Plan as needed

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FY 2018
(Interim Year 03 of Previous Reporting Cycle)
 Enter the FY 2018 Annual Indicator Data
(specifically, the Numerator, Denominator,
Data Source and Data Note) for the
Selected NPMs, ESMs and SPMs
 Report on FY 2018 Program Activities and
Analyze Performance, by MCH Health
Domain, using New Narrative Format
 Enter Expenditure Data on Forms #2, #3a,
and #3b

Submission
Date

Application Year

Annual Report Year

FY 2020 (Continued)

FY 2018 (Continued)

 Complete Narrative Sections of
Application, including Presentation of the
State’s Five-year Action Plan by MCH
Health Domain
 Enter Budgeted Data for Application Year
on Forms #2, #3a and #3b
 Update Listed Names of MCH Director,
CSHSN Director and Family/Youth Leader
on Form #8

 Enter Required Data (i.e., Newborn and
Others Screening, Unduplicated Count and
Total Encounters of Individuals Served,
Deliveries and Infants Served by Title V and
Entitled to Benefits Under Title XIX and
State Toll-free Hotline and Other
Appropriate Methods Data) on Forms #4,
#5a, #5b, #6 and #7 for the Reporting Year.

 Review Other State Data (OSD) on
Form #11 and Form #10A for NOMs
July 15, 2020

FY 2021
(First Application Year of New Five-year
Reporting Cycle)
 Complete Application for Federal
Assistance (Standard Form - 424)
 Develop Executive Summary for
Application
 Include Needs Assessment Summary in the
Application
 Identify 7-10 Priority Needs (Form #9)
 Select at least 5 National Performance
Measures (NPMs) and Enter Five-year
Performance Objectives on Form #10A
 Develop Evidence-based or -informed
Strategy Measures (ESMs) for Each
Selected NPM; Prepare Detail Sheet for
each ESM on Form #10C; and Enter Fiveyear Performance Objectives for Each ESM
on Form #10A
 Develop SPMs to Address Priority Needs
Not Addressed Through the NPMs and
ESMs; Prepare Detail Sheet for Each SPM
on Form #10B; and Enter Five-year
Performance Objectives for Each SPM on
Form #10A
 Prepare Five-Year State Action Plan Table
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FY 2019
(Interim Year 04 of Previous Reporting Cycle)
 Enter the FY 2019 Annual Indicator Data
(specifically, the Numerator, Denominator,
Data Source and Data Note) for the
Selected NPMs, ESMs and SPMs
 Report on FY 2019 Program Activities and
Analyze Performance, by Population
Health Domain, in the State Action Plan
 Enter Expenditure Data on Forms #2, #3a,
and #3b
 Enter Required Data (i.e., Newborn and
Others Screening, Unduplicated Count and
Total Encounters of Individuals Served,
Deliveries and Infants Served by Title V and
Entitled to Benefits Under Title XIX and
State Toll-free Hotline and Other
Appropriate Methods Data) on Forms #4,
#5a, #5b, #6 and #7 for the Reporting Year

Submission
Date

Application Year

Annual Report Year

FY 2021 (Continued)
 Complete Narrative Sections of
Application, including Presentation of the
State’s Five-year Action Plan by MCH
Health Domain
 Enter Budgeted Data for Application Year
on Forms #2, #3a and #3b
 List Names of MCH Director, CSHSN
Director and Family/Youth Leader on
Form #8
 Review Other State Data (OSD) on
Form #11 and Form #10A for National
Outcome Measures (NOMs)

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APPENDIX H:

GLOSSARY

A comprehensive glossary of terms relevant to maternal and child health (MCH) practice,
including services for children with special health care needs (CSHCN), is available on the MCH
Navigator site. To access the Glossary, click on:
(https://www.mchnavigator.org/documents/Glossary_of_MCH_Terms_and_Acronyms_201211-17.pdf). This project is administered by Georgetown University through funding provided by
the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau
(MCHB.) The MCH Navigator is a learning portal for MCH professionals, students, and others
working to improve the health and well-being of women, children, adolescents, and families.
Definitions included in this Glossary are intended to supplement the broader set of terms that
are included in the MCH Navigator Glossary. The following list of terms and their definitions
have specific relevance to the State Title V MCH Block Grants.

MCH Working Framework: MCH Pyramid of Services

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As depicted on the Revised MCH Pyramid, the working framework for the MCH Block Grant
aligns with the 10 MCH Essential Services and consists of three levels. Definitions are provided
below for each level of service. In developing systems of care, states should assure that they
are family-centered, community-based and culturally competent.
Direct Services – Direct services are preventive, primary, or specialty clinical services
to pregnant women and children, including children with special health care needs, where MCH
Services Block Grant funds are used to reimburse or fund providers for these services through a
formal process similar to paying a medical billing claim or managed care contracts. State
reporting on direct services should not include the costs of clinical services which are delivered
with Title V dollars but reimbursed by Medicaid, CHIP or other public or private payers.
Examples include, but are not limited to, preventive, primary or specialty care visits, emergency
department visits, inpatient services, outpatient and inpatient mental and behavioral health
services, prescription drugs, occupational and physical therapy, speech therapy, durable
medical equipment and medical supplies, medical foods, dental care, and vision care.
Enabling Services – Enabling services are non-clinical services (i.e., not included as direct or
public health services) that enable individuals to access health care and improve health
outcomes where MCH Services Block Grant funds are used to finance these services. Enabling
services include, but are not limited to: case management, care coordination, referrals,
translation/interpretation, transportation, eligibility assistance, health education for individuals
or families, environmental health risk reduction, health literacy, and outreach. State reporting
on enabling services should not include the costs for enabling services that are reimbursed by
Medicaid, CHIP, or other public and private payers. This category may include salary and
operational support to a clinic that enable individuals to access health care or improve health
outcomes. Examples include the salary of a public health nurse who provides prenatal care in a
local clinic or compensation provided to a specialist pediatrician who provides services for
children with special health care needs.
Public Health Services and Systems – Public health services and systems are activities and
infrastructure to carry out the core public health functions of assessment, assurance, and policy
development, and the 10 essential public health services. Examples include the development
of standards and guidelines, needs assessment, program planning, implementation, and
evaluation, policy development, quality assurance and improvement, workforce development,
and population-based disease prevention and health promotion campaigns for services such as
newborn screening, immunization, injury prevention, safe-sleep education and anti-smoking.
State reporting on public health services and systems should not include costs for direct clinical
preventive services, such as immunization, newborn screening tests, or smoking cessation.

Number of Individuals and Percentage of Populations Served by Title V
(Form 5)
Form 5a, Count of Individuals Served by Title V, enables the state to track and report on the
number of who received an individually-delivered service funded in part or in full by the Title V
95

program within the top two levels of the MCH Pyramid (direct and enabling services). This
includes individuals receiving services funded by total Federal and State dollars reported on line
8 of Form 2, and should align with the combined totals on Form 3a and 3b for direct and
enabling services. Data sources are typically reimbursement or individual client records.
Pregnant women may also receive non-pregnancy related services and be counted in other
participant categories (i.e. children ages one (1) through 21 and others). All remaining
categories are mutually exclusive with CSHCN reported as a subset of all children ages one (1)
through 21. Within each reporting category, the count of individuals served should be
unduplicated to the fullest extent possible. Examples of direct and enabling services by
participant category that Title V may fund in part or in full are provided below.
Pregnant women (through 60 days postpartum) – payment for prenatal, delivery, or
postpartum care, case management, insurance eligibility assistance.
Infants (less than age one) – payment for well child visits, immunization, case management.
Children ages one (1) through 21, including CSHCN – payment for well child visits, immunization,
dental sealants, school-based health center services, specialty care services and care
coordination.
Others (women and men over 21) – payment for well-woman visits, education or familycentered care provided to parents/guardians of children.
Form 5b, Total Percentage of Populations Served by Title V, enables the state to track and
report on the total percentage who received a Title V-supported service within all levels of the
MCH Pyramid (direct services, enabling services, and public health services and systems). The
purpose of this form is to better capture the breadth of the State’s Title V program and its reach
in serving the MCH population. Included in this reporting are all individuals and populations
served by the total Federal and State dollars, as reported on line 8 of Form 2, and the combined
totals on Form 3a and 3b for all service levels. Non-Title V programs that provide direct and
enabling services (e.g., WIC and Home Visiting) may be included if Title V funds or staff time are
used to promote or enhance services. (Individual services that are Title V-funded may also be
counted in Form 5a.) To avoid duplication, numerators for the percentage estimate should
focus on the programs and services that have the largest reach for a given population, which
generally involves the public health services and systems level of the MCH Pyramid.
Approximate denominators for each population group will be provided to facilitate percentage
estimation. Within public health services and systems, only those reached by activities directly
connected to promoting the access or quality of specific population-based services and systems
should be counted. Examples of these public health services and systems activities, as well as
direct/enabling service partnerships, are provided below by participant category.
Pregnant women (through 60 days postpartum)
• Develop and/or maintain a system of risk-appropriate perinatal care designations and
transfer protocols (count 100%).
96

•
•
•
•

Fund local health departments to engage provider groups and promote screening for
perinatal depression, smoking or substance use (count number or percent of births in
funded counties).
Partner with Medicaid or other health plans to implement a policy/procedural change to
reduce low-risk cesarean delivery or promote smoking cessation (count number or %
served by Medicaid or other health plans).
Outreach to hospitals to institute a safe sleep or baby friendly policy, distribute
educational materials, or participate in a QI collaborative (count number or % of births
in participating hospitals).
Partner with WIC or home visiting programs to provide staff training or otherwise
promote education, screening, or referrals on smoking cessation or preventive dental
services (count number or % of pregnant/postpartum women served).

Infants (less than age one)
• Administer, develop guidelines/standards/policies, or otherwise assure the newborn
screening program (count 100%).
• Develop and/or maintain a system of risk-appropriate perinatal care designations and
transfer protocols (count 100%).
• Outreach to hospitals to institute a safe sleep or baby friendly policy, distribute
educational materials, or participate in a QI collaborative (count number or % of infants
served).
• Partner with WIC or home visiting programs to provide staff training or otherwise
promote education/counseling on safe sleep practices (count number or % of
pregnant/postpartum women served).
• Implement a statewide campaign to promote safe sleep practices (count number of
Web hits).
Children ages one (1) through 21, including CSHCN
• Develop and maintain a statewide registry for developmental screening and follow-up
(count number of children age one (1) through 5).
• Develop or promote school-based injury prevention, oral health, or physical activity
programs (count number of children in participating schools).
• Partner with Medicaid, health plans, pediatric practices, or schools to implement a
policy/procedural change, QI collaborative, or other campaign to promote the
adolescent well visit (count number of adolescents enrolled or served by
plan/practice/school).
• Fund local health departments to promote and advance the medical home model
among all pediatric providers (count number of children in local counties).
• Develop and maintain a comprehensive system of services for CSHCN (count number of
CSHCN served; if percentage served is lower than other population-based services for all
children, report service percentage for all children as CSHCN are not excluded from
general services).

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Others (women and men over age 21)
• Implement a statewide campaign to promote the well-woman visit (count number of
web hits)
• Partner with WIC or Home Visiting to improve screening/counseling for smoking
cessation (count number of women with a child age one (1) or more to avoid duplication
with pregnant women)
• Partner to promote family engagement services (count number of parents over 21
served)

Title V Program Administration
Administrative Title V Funds - The amount of funds the state uses for the management of the
Title V allocation. This amount is limited by statute to 10 percent of the Federal Title V
allotment.
Capacity – Program capacity includes delivery systems, workforce, policies, and support
systems (e.g., training, research, technical assistance, and information systems) and other
infrastructure needed to maintain service delivery and policy making activities. Program
capacity results measure the strength of the human and material resources necessary to meet
public health obligations. As program capacity sets the stage for other activities, program
capacity results are closely related to the results for process, health outcome, and risk factors.
Program capacity results should answer the question, “What does the state need to achieve the
results we want?”
Budget Period – Grant period for which funds are available for use by the state. For the MCH
Block Grant, the budget period is 24 months, beginning on October 1 of the federal fiscal year
in which the funds are awarded and ending on September 30 of the following federal fiscal
year.
Children – A child from age one (1) through 21 years.
Data Systems Development – Development of data management systems (electronic or other)
or linking of existing databases to support states’ ability to collect, tabulate, analyze, and report
data accurately.
Early Neonatal Period – Period covered by the first week after birth or an age of less than seven
days.
Federal Allocation – The funding provided to the states under the Federal Title V Block Grant in
any given fiscal year; applies specifically to the Application Face Sheet (SF-424) and Form 2.
Federal Fiscal Year: The federal government’s fiscal year begins on October 1 and ends on
September 30 of the following year.
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Government Performance and Results Act (GPRA) – Federal legislation enacted in 1993 that
requires Federal agencies to develop strategic plans, prepare annual plans setting performance
goals, and report annually on actual performance.
Infants – Children in their first year of life (<365 days).
Jurisdictions – The following nine jurisdictions receive Title V Maternal and Child Health Block
Grant Program funding: the District of Columbia, the Republic of the Marshall Islands, the
Federated States of Micronesia, the Republic of Palau and the U.S. territories of the
Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the
Commonwealth of the Northern Mariana Islands.
Life Course Theory (LCT) – A conceptual framework that helps explain health and disease
patterns, particularly health disparities, across populations and over time. Instead of focusing
on differences in health patterns based on one disease or condition at a time, LCT points to
broad social, economic and environmental factors as underlying causes of persistent
inequalities in health for a wide range of diseases and conditions across population groups. LCT
is population focused, and firmly rooted in social determinants and social equity models.
Though not often explicitly stated, LCT is also community (or “place”) focused, since social,
economic and environmental patterns are closely linked to community and neighborhood
settings. 7
Local – Funds derived from local health jurisdictions within the state, which are used for MCH
program activities and reported on the Application Face Sheet (SF 424) and Form 2.
Low Income – An individual or family with an income that is determined to be below the
income official federal poverty line, as defined by the Office of Management and Budget and
revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of
1981. [Title V, Sec. 501 (b)(2)]
Maintenance of Effort – State will maintain the level of funds being provided solely by such
state for maternal and child health programs at a level at least equal to the level provided in
FY 1989.
Needs Assessment – A process to understand the strengths and needs of the health service
system within a community or population. For maternal and child health purposes, needs
assessment efforts consider the following components: 1) health status, 2) health service
utilization, 3) health systems capacity, and 4) population/ community characteristics and
contextual characteristics.
Neonatal Period – period covered by the first month after birth or an age of less than 28 days.
7

https://mchb.hrsa.gov/training/lifecourse.asp

99

Newborn – A recently born infant, usually less than one month old.
Objectives – A statement of intention with which actual achievement and results can be
measured and compared. SMART objectives are Specific, Measurable, Achievable, Relevant
and Time-phased. See also Objectives and Performance Objectives within the Performance
Measurement Section.
Other Federal Funds – Federal funds other than the Title V Block Grant that are under the
control of the person responsible for administration of the Title V program and reported on the
Application Face Sheet (SF 424) and Form 2. These funds may include, but are not limited to:
WIC, EMSC, Healthy Start, SPRANS, HIV/AIDs monies, CISS funds, MCH targeted funds from
CDC, MCH Education funds and Medicaid Federal Medical Assistance Percentage (FMAP).
Others (Class of Individuals) – Women and men, over age 21.
Perinatal – Period pertaining to immediately before and after birth. For example, the definition
of perinatal mortality refers to fetal and early neonatal death between 28 weeks or more
gestation through the first week of life (less than seven days after birth).
Postneonatal Period – Period of infant age from one month (28 days) up to one year (<365
days).
Pregnant Woman – A female from the time that she conceives to 60 days after birth, delivery,
or expulsion of fetus.
Prenatal – Occurring or existing before birth, referring to both the care of the woman during
pregnancy and the growth and development of the fetus.
Priority Needs – Title V legislation direct states to conduct a statewide, comprehensive MCH
Needs Assessment every five years to identify the need for preventive and primary care
services for pregnant women, mothers, infants, children and children with special health care
needs. From this assessment, states select seven to ten priorities for focused programmatic
efforts over the five-year reporting cycle.
Program Income – Funds collected by State MCH agencies from sources generated by the
State’s MCH program to include insurance payments, Medicaid reimbursements, HMO
payments, etc., as reported on the Application Face Sheet [SF 424] and Form 2.
State – Terminology used in this Guidance to reference the 50 states and the nine jurisdictions.
(See also “Jurisdictions”)
State Funds – The state’s required matching funds (including overmatch) in any given year, as
reported on the Application Face Sheet [SF 424] and Form 2.
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Strategies – General approaches taken to achieve objectives: activities are specific actions to
implement the strategies. For example, a strategy may be to improve provider training with
activities that could include developing a training module, delivering or promoting the training,
and monitoring utilization and/or knowledge improvement. Program activities for
implementing the identified program strategies are discussed and updated annually as part of
the State Action Plan narrative.
Technical Assistance (TA) – The process of providing advice, assistance, and training by an
expert with specific technical/content knowledge to address an identified need. Technical
Assistance relationships are program-focused, and may use an interactive, on-site/hands-on
approach as well as telephone or email assistance. Technical Assistance delivery is short in
duration, customized to meet the needs of the client, and offers prescriptive solutions to a
specific issue.
Title V of the Social Security Act – The authorizing legislation for the Maternal and Child Health
Services Block Grant to States Program.
Title V Reporting Form 6, Deliveries to Pregnant Women Served by Title V – Unduplicated
number of deliveries to pregnant women who were provided prenatal, delivery, or post-partum
services through the Title V program during the reporting period.
Title V Reporting Form 6, Infants Served by Title V – The unduplicated count of infants provided
a direct service by the State’s Title V program during the reporting period.
Title XIX of the Social Security Act – The authorizing legislation for the Medicaid program.
Title XIX Reporting on Form 6, Pregnant Women Eligible for Title XIX – The number of pregnant
women who delivered during the reporting period and were eligible for the State’s Title XIX
(Medicaid) program.
Title XIX Reporting on Form 6, Infants Eligible for Title XIX – The number of infants eligible for
the State’s Title XIX (Medicaid) program.
Title XXI of the Social Security Act – Children’s Health Insurance Program (CHIP) financed via the
Centers for Medicare and Medicaid Services (CMS). The purpose of this title is to provide funds
to states to enable them to initiate and expand the provision of child health assistance to
uninsured, low-income children in an effective and efficient manner that is coordinated with
other sources of health benefits coverage for children. (Sec. 2101. [42 U.S.C. 1397aa])
Total MCH Funding – All of the MCH funds administered by a State MCH program. Included in
this sum total are: 1) the Federal Title V Block grant allocation; 2) the Applicant’s funds, which
consists of the unobligated balance from the previous year’s MCH Block Grant allocation, the
state’s total matching funds for the Title V allocation (match and overmatch); 3) the Local
101

funds, which are the total amount of MCH dedicated funds from local government within the
state); 4) Other Federal funds (monies other than the Title V Block Grant that are under the
control of the person responsible for administration of the Title V program), and 5) Program
Income (funds collected by State MCH agencies from insurance payments, Medicaid, HMO’s,
private grants, etc.)
Unobligated Balance – The amount of unexpended funds from the previous project period for
Title V MCH Block Grant, as reported as Applicant funds on the Application Face Sheet [SF 424]
and as Unobligated Balance on Form 2.

Performance Measurement
Evidence-based or –Informed Strategy Measure (ESM) –Developed by the state, ESMs assess
the outputs of State Title V strategies and activities contained in the State Action Plan. The
development of ESMs is guided through an examination of evidenced-based or evidenceinformed strategies, and determining what components are meaningful, measurable, and
achievable. The main criteria for ESMs are in being meaningfully related to the selected NPM
through scientific evidence or theory and being measurable by the state with improvement
achievable in multiple years of the five-year reporting cycle.
Evidence-based or –Informed Strategy Measure (ESM) Objectives – The objectives for activities
and interventions that drive the achievement of higher-level objectives by the State Title V
program.
Objectives – The yardsticks by which an agency can measure its efforts to accomplish a goal.
(See also Performance Objectives)
Outcome Measure – The ultimate focus and desired result of any set of public health program
activities and interventions is an improved health and well-being outcome. Health and wellbeing outcomes are usually longer term and tied to the ultimate program goal. Morbidity and
mortality statistics are indicators of achievement of health outcomes. Other outcomes reflect
commonly accepted indicators of a highly functioning system of care for children with special
health care needs and their families, positive outcomes, outcomes which are legislatively
mandated or are a legislative focus, outcomes where the prevalence is increasing, and
developmental outcomes where a fully established measure does not exist.
Performance Indicator – The statistical or quantitative value that expresses the result of a
performance objective.
Performance Measure – An intermediate outcome on the path toward a longer term outcome
measure of health and well-being that is used to more directly assess the impact of a program.
Positive health behaviors and access to quality health care are common intermediate outcomes
that may lead to health, reduced morbidity and mortality, or highly functioning systems of care.
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For example, to reduce infant mortality, State Title V programs may work to promote safe sleep
practices or access to quality well-woman care. The performance measure is phrased as a
quantitative indicator, such as a rate or percentage. For example, “Percentage of infants placed
to sleep on their backs.”
Performance Measurement – The collection of data on, recording of, or tabulation of results or
achievements, usually for comparison to a benchmark.
Performance Objectives – A statement of intention with which actual achievement and results
can be measured and compared. Performance objective statements clearly describe what is to
be achieved, when it is to be achieved, the extent of the achievement, and the target
populations. For example: “Increase the percentage of infants placed to sleep on their backs in
State X by 10% over the next 5 years.”
Risk Factors – Public health activities and programs that focus on reduction of scientifically
established direct causes of, and contributors to, morbidity and mortality (i.e., risk factors) are
essential steps toward achieving desired health outcomes. Changes in behavior or physiological
conditions are the indicators of achievement of risk factor results. Results focused on risk
factors tend to be intermediate term. Risk factor results should answer the question, “Why
should the state address this risk factor (i.e., what health outcome will this result support)?”
Risk Factor Objectives – Objectives that describe an improvement in risk factors (usually
behavioral or physiological) that are associated with morbidity and mortality.
Targets – An aspired outcome that is explicitly stated, e.g. “Attain 90% of timeliness in
reporting” or ”Achieve 100% completeness of reporting”, etc. In this Guidance, “Targets” is
often used interchangeably with “Objectives.”

Collaborative Learning, Innovation and Quality Improvement
Aim Statement – A written measureable description of desired outcomes used in a quality
improvement initiative. A strong AIM statement outlines what is to be accomplished,
quantifies the changes that are to be achieved and sets a date by which the goals will be
reached.
Blueprint for Change – A tool to help define action steps for a team’s strategic priorities.
CoIIN versus COIN – The Collaborative Improvement and Innovation Network (CoIIN) initiative
extends the Collaboration Innovation Network (COIN) model to include the concept of
improvement in recognition of the need to strengthen existing investments in maternal and
infant health as well as to develop innovative, new approaches.

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Collaborative Innovation Network (COIN) – A cyberteam of self-motivated people with a
collective vision, enabled by the Web to collaborate in achieving a common goal by sharing
ideas, information and work. 8
Collaborative Learning – Projects using this model enable learners of different abilities and
interests to work jointly in small groups to complete a project or solve a problem.
Collective Impact – A concept that provides a framework for bringing diverse people and
organizations together in a structured way to achieve social change.9
Driver Diagram – A logic chart that organizes the different aspects of an improvement project
so key interventions and relationships between these interventions may be clearly understood
by all involved.
Infant Mortality CoIIN Framework – A framework that presents a theory of the relationships
between (1) key domains of influence (e.g., engaged leadership or innovation), (2) the periods
of engagement, and (3) the strategies priorities that will be employed to reduce infant mortality
rates in the U.S.
Learning Collaborative – A group of individuals or organizations that come together for a
defined period of time to work together to improve process relevant to a specific topic.
Members of a learning collaborative generally agree upon a shared set of data to measure and
meet regularly to learn from each other and project experts.
Learning Sessions – Members of learning collaboratives generally agree to a regular schedule of
multi-day meetings throughout the collaborative. These meetings may be in person or virtual.
The learning sessions allow Collaborative faculty and partners to share latest research or
important information on the topic of the collaborative, and they allow participants to share
their work and to learn from each other.
Perinatal Periods of Risk (PPOR) – Both a community approach and an analytic framework for
investigating and addressing high infant mortality rates in urban settings. The overall intent of
the PPOR approach is to develop a simple method that can be used by communities to mobilize
and prioritize prevention efforts. PPOR brings community stakeholders together to build
consensus, support and partnership around infant mortality rates. 10
Primary Drivers – Found in the CoIIN framework and driver diagrams, drivers are system
components, factors or broad improvement areas that contribute directly to achieving the
stated outcome. For example, if the outcome is reducing infant mortality, a strategic

8

9
10

Gloor, Peter A. “Swarm Creativity.” Competitive Advantage through Collaborative Innovation
Networks. (2006)
http://collectiveimpactforum.org/what-collective-impact
http://www.citymatch.org/projects/perinatal-periods-risk-ppor

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priority/primary driver might be to improve access to and quality of prenatal care for women.
(See Strategic Priorities.)
Potential Action/Change Concept – Actionable steps for change targeted at improving specific
processes, often originating from brainstorming sessions with the team and evidence-based
best practices.
Quality Improvement in Public Health – The use of a deliberate and defined improvement
process, which is focused on activities that are responsive to community needs and improving
population health. This effort is continuous and ongoing to achieve measureable
improvements in the efficiency, effectiveness, performance, accountability, outcomes and
other indicators of quality in services or processes, which achieve equity and improve the
health of the community.
Strategic Priorities – Found in the CoIIN framework and driver diagrams, these priorities are
system components, factors or broad improvement areas that contribute directly to achieving
the stated outcome. For example, if the outcome is reducing infant mortality, a strategic
priority/primary driver might be to improve access to and quality of prenatal care for women.

Family Partnership
Cultural Competence – A set of values, behaviors, attitudes, and practices within a system,
organization, program or among individuals and which enables them to work effectively cross
culturally. Further, cultural competence refers to the ability to honor and respect the beliefs,
language, inter-personal styles and behaviors of individuals and families receiving services, as
well as staff who are providing such services.
Culturally Sensitive – The recognition and understanding that different cultures may have
different concepts and practices with regard to health care; the respect of those differences
and the development of approaches to health care with those differences in mind.
Family Partnership – For purposes of the MCH Block Grant, family partnership is defined as
patients, families, their representatives, and health professionals working in active partnership
at various levels across the health care system—direct care, organizational design and
governance, and policy making—to improve health and health care. This partnership is
accomplished through the intentional practice of working with families for the ultimate goal of
positive outcomes in all areas through the life course. 11 Additional references include, but are
not limited to, several comprehensive reports written by the Association of Maternal and Child
Health Programs (AMCHP) that describe family engagement efforts in State Title V programs.
11

Carman K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtcl, C., Sweeney, J. Patient and Family
Engagement: A framework for understanding the elements and developing interventions and policies. Health
Affairs. 2013; 32:223-231.

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These references are available at: http://www.amchp.org/programsandtopics/familyengagement/Pages/default.aspx.
Patient- and Family-Centered Care – “An approach to the planning, delivery, and
evaluation of health care that is grounded in a mutually beneficial partnership among
patients, families, and providers that recognizes the importance of the family in the
patient’s life.” 12 “This approach recognizes that the perspectives and information
provided by families, children, and young adults are essential components of highquality clinical decision-making, and that patients and family are integral partners
with the health care team.” 13

Children with Special Health Care Needs
Care Coordination Services – Services that promote the effective and efficient organization and
utilization of resources to assure access to necessary comprehensive services for children with
special health care needs and their families. [Title V Sec. 501(b)(3)] Pediatric care coordination
is “patient and family centered, assessment driven, team based.14 Care coordination services
facilitate linkage of children and their families with appropriate services and resources that
meet their health and social needs to achieve optimal health. This care is to be distinguished
from case management which primarily focuses on the children’s medical issues. 15
Case Management Services – Services that assure access to quality prenatal, delivery and
postpartum care for pregnant women; and services that assure access to quality preventive and
primary care services for infants up to age one (1). [Title V Sec. 501(b)(4)]
Children With Special Health Care Needs (CSHCN) – Children with special health care needs are
those who have or are at increased risk for a chronic physical, developmental, behavioral, or
emotional condition and who also require health and related services of a type or amount
beyond that required by children generally. 16 For Form 5 reporting, only CSHCN ages one (1)
through 21 are captured separately as a subset of all children to avoid duplication with infants
who are commonly served universally through newborn screening
Systems of Services for Children with Special Health Care Needs – A system of services for
children with special health care needs is a “family-centered coordinated network of
community-based services designed to promote the healthy development and well-being of
Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient- and Family-Centered
Care and the Pediatrician’s Role. Pediatrics. 2012; 129: 394
13
Ibid.
14
Antonelli RC, McAllister J, Popp J. 2009. Developing Care Coordination as a critical component of a high
performance pediatric health care system. Washington DC: The Commonwealth Fund
15
Turchi RM, Mann M. Building a medical home for children and youth with special health care needs. In: Hollar
D, ed. Handbook of Children with Special Health care Needs. New York, NY: Springer-Verlag; 2013:399-418.
12

16

McPherson M., Arango P., Fox H. A new definition of children with special health care needs. Pediatrics. 1998; 102: 137-140.

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children and their families”. 17 Additionally, a “well-functioning system of services will
coordinate and integrate the full range of needed child and family services, including health
care, education, and social services, with the goal of optimizing outcomes for the children and
families it serves.” 18
Key frameworks describing the system of services for CSHCN:
• Six Core Outcomes for CSHCN 19,20
o Family Professional Partnership
o Medical Home
o Adequate Health Insurance
o Early and Continuous Screening and Surveillance
o Easy to Use Services and Supports
o Transition to Adult Health Care
•

National Standards for Systems of Care for Children and Youth with Special Health Care
Needs
o The National Systems Standards describe the process and provide a framework
necessary to build an effective system of services for CSHCN. The standards are
divided into ten core domains, and they are based on the six core outcomes
listed above for CSHCN. Additional information is available at:
http://www.amchp.org/AboutTitleV/Resources/Documents/Standards%20Char
ts%20FINAL.pdf.

Additional MCH Terms
Acquired Brain Injury – Injury to the brain that is not hereditary, congenital, degenerative, or
induced by birth trauma. Traumatic brain injury is a type of acquired brain injury.
Bullying – Unwanted, aggressive behavior among school aged children that involves a real or
perceived power imbalance. The behavior is repeated, or has the potential to be repeated,
over time. Additional guidance on bullying surveillance is available at:
http://www.cdc.gov/violenceprevention/pdf/bullying-definitions-final-a.pdf.

17
Perrin, J., Romm, D., Bloom, S., Homer, C., Kuhlthau, K., Cooley, C., Duncan, P., Roberts, R., Sloyer, P., Wells, N., Newacheck, P. A familycentered, community-based system of services for children and youth with special health care needs. 2007; 161 (10): 933-936.

Ibid.
National Agenda for Children with Special Health Care Needs: Achieving the Goals 2000. Washington, D.C.: Health Resources
Services Administration; 1999.
20 Strickland, B., van Dyck, P., Kogan, M., Lauver, C., Blumberg, S., Bethell, C., Newacheck, P. Assessing and ensuring a
comprehensive system of services for children with special health care needs: a public health approach. 2011; 101 (2): 224-231.
18
19

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Clinical Genetics – Clinical and laboratory services for individuals and families with, or at risk for,
health problems with a heritable component. The application of the principles of genetics and
genomics to predict, diagnose, and treat disease and improve health.
Community – A group of individuals living as a smaller social unit within the confines of a larger
one due to common geographic boundaries, a common work environment, common interests
and other uniting factors.
Community-based Care – Services provided within the context of a defined community.
Community-based Service System – An infrastructure that operates across service sectors that
facilitates the integration of services in several dimensions, which includes organization,
delivery, and financing.21
Genetic Counseling: The process of helping people to understand and adapt to the medical,
psychological, and familial implications of genetic contributions to disease. This process
integrates: interpretation of family and medical history to assess the chance of disease
occurrence or recurrence; education about inheritance, testing, management, prevention,
resources and research; counseling to promote informed choices; and adaptation to the risk or
condition.
Health Care System – The entirety of the agencies, services, and providers involved or
potentially involved in the health care of community members and the interactions among
those agencies, services and providers.
Human Genetics: The science of genes, heredity and variation in human organisms
Health Care Transition – The process of moving from a child to an adult model of health care.
The goal of health care transition (HCT) is to optimize health and assist youth in reaching their
full potential, which requires an active process over time that addresses many aspects of a
youth’s life, including medical, psychosocial, educational, and vocational needs. This process
also ensures continuity of developmental and age appropriate health care services. Successful
transition involves the engagement and participation of the pediatric and adult medical home
team, the family and other care givers, and the individual youth collaborating in a positive and
mutually respectful relationship. 22 For more information see http://www.gottransition.org/
Medical Home – An approach to providing comprehensive, high quality health care that is
accessible, family-centered, continuous, comprehensive, coordinated and compassionate.23
U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health
Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2009–2010. Rockville, Maryland: U.S.
Department of Health and Human Services, 2013.
22 American Academy of Pediatrics. American Academy of Family Physicians and American College of Physicians. Transitions
Clinical Report Authoring Group. Supporting the health care transition from adolescence to adulthood in the medical home.
Pediatrics. 2011;
23 American Academy of Pediatrics. Organizational principles to guide and define the child health care system and/or improve
21

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Care occurs in an environment of trust and mutual responsibility between the family, patient,
and primary care provider. The principle of family-centered care defines the care to be
received in a medical home while a team-based approach is central to delivering care in the
medical home. Within the medical home, care coordination addresses interrelated medical,
dental, mental and behavioral, social, educational, and financial needs to achieve optimal
health and wellness outcomes. Additional information is available at:
https://medicalhomeinfo.aap.org/Pages/default.aspx.
Morbidity – A general term for any health condition that encompasses diseases, injuries, and
impairments in a population or group.
Mortality – A general term for the incidence of deaths in a population or group. The number of
deaths may be reported by age, sex, race/ethnicity, geographic area, and cause of death.
Mortality Rate – The number of deaths occurring in a particular population during a specific
time period, as calculated by the number of deaths in that group (numerator) divided by the
total population (denominator) and expressed as per 1,000 live births (infant mortality rate
only) or per 100,000 population, generally at mid-year.
National Improvement Partnership Network (NIPN) – A network of states who have an
Improvement Partnership (IP), which is a durable collaborative of public and private partners
that use the science of quality improvement and a systems approach to improve health care
infrastructure and practice. Established in 2009, NIPN is led by the Vermont Child Health
Improvement Program (VCHIP).
National Survey of Children’s Health (NSCH) – Sponsored by the Maternal and Child Health
Bureau of the Health Resources and Services Administration, the NSCH examines the physical
and emotional health status and health service needs and utilization patterns of children ages
0-17 years of age. Special emphasis is placed on factors that may relate to well-being of
children, including medical homes, family interactions, parental health, school and after-school
experiences, and safe neighborhoods. The NSCH was fielded three times as a telephone-based
survey, in 2003, 2007 and 2011-2012, yielding both state- and nationally-representative data.
In 2016, the NSCH underwent a significant redesign, becoming an annual address-based mailed
survey with a web-based response option that merged content from the previous NSCH and
National Survey of Children with Special Health Care Needs (NS-CSHCN).
https://mchb.hrsa.gov/data/national-surveys
National Survey of Children with Special Health Care Needs (NS-CSHCN) – This survey was
sponsored by the Maternal and Child Health Bureau of the Health Resources and Services
Administration. The NS-CSHCN was conducted three times as a telephone-based survey, in
2001, 2005-2006 and 2009-2010, and yielded state- and nationally-representative data on the
health care experiences of CSHCN and their families. In 2016, the NS-CSHCN was merged with
the health of all children. Pediatrics; 110 (1): 2002

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the NSCH to provide one unified survey administered annually by mail with a web-based
response option. Additional information is available at: https://mchb.hrsa.gov/data/nationalsurveys.
Newborn Screening (NBS) – The process of testing newborn babies for some serious, but
treatable, conditions. Four million newborns each year are tested for conditions on the
Recommended Uniform Screening Panel (a set of conditions recommended by the Secretary of
HHS for NBS) that are not apparent at birth but require early intervention and treatment to
mitigate brain and organ damage, severe illness, and life-threatening complications associated
with these conditions. NBS can include a heel stick, hearing screen, and pulse oximetry. The
conditions that newborn babies are screened for varies by state. When a newborn screening
result is out-of-range, further diagnostic testing is required to confirm or specify the results.
Newborn Screening Long-term Follow-up – Comprises the assurance and provision of ongoing
quality chronic disease management, condition-specific treatment, and age-appropriate care
throughout the lifespan of individuals identified with a condition included in newborn
screening.
Newborn Screening Short-term Follow-up – The process of ensuring that all newborns are
screened, that an appropriate follow-up caregiver is informed of results, that confirmatory
testing has been completed, and that the infant has received a diagnosis and, if necessary,
treatment is initiated.
Preventive Services – Activities aimed at reducing the incidence of health problems or disease
prevalence in the community, or the personal risk factors for such diseases or conditions.
Preventive Oral Health Services – Activities that aim to improve and maintain good oral health
and function by reducing the onset and/or development of oral diseases or deformities and the
occurrence of oro-facial injuries. Examples of preventive oral health services include, but are
not limited to, oral hygiene instructions, fluoride treatment, and Dental Sealants.
Primary Care/Primary Care Services – The provision of comprehensive personal health services
that include health maintenance and preventive services, initial assessment of health problems,
treatment of uncomplicated and diagnosed chronic health problems, and the overall
management of an individual’s or family’s health care services.
Recommended Uniform Screening Panel (RUSP) – The RUSP is a list of disorders that are
recommended by the Secretary of the Department of Health and Human Services (HHS) for
states to screen as part of their state universal newborn screening (NBS) programs. Disorders
on the RUSP are chosen based on evidence that supports the potential net benefit of screening,
the ability of states to screen for the disorder, and the availability of effective treatments. It is
recommended that every newborn be screened for all disorders on the RUSP. Most states
screen for the majority of disorders on the RUSP; newer conditions are still in process of
adoption. Some states also screen for additional disorders. Although states ultimately
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determine what disorders their NBS program will screen for, the RUSP establishes a
standardized list of disorders that have been supported by the Advisory Committee on
Heritable Disorders in Newborns and Children and the Secretary of HHS.
Safe Infant Sleep Environment – Infant is placed to sleep on its back, in its own crib without
blankets or soft items or bed-sharing. Additional information is available at:
http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284
Sudden Unexpected Infant Deaths (SUID) - Deaths in infants less than one year of age that
occur suddenly and unexpectedly, and in whom the cause of death is not immediately obvious
prior to investigation.
Sudden Infant Death Syndrome (SIDS) – The sudden death of an infant less than one year of age
that cannot be explained after a thorough investigation is conducted, including a complete
autopsy, examination of the death scene, and review of the clinical history.
Systems Development – Activities involving the creation or enhancement of organizational
infrastructures at the community level for the delivery of health services and other needed
ancillary services to individuals in the community by improving the service capacity of health
care service providers.
Traumatic Brain Injury – An alteration in brain function, or other evidence of brain pathology
caused by an external force.

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