Maternal Infant Early Childhood Home Visiting (MIECHV) Grant Program

Request for Proposal Materials

Grant Period: January 1, 2017 – September 30, 2019

Proposal Deadline: Friday, July 15, 2016

Division of Community and Family HealthFamily Home Visiting Section85 East 7th PlaceP.O. Box 64882St. Paul, Minnesota 55164-0882651-201-4090

Maternal Infant Early Childhood Home Visiting (MIECHV) Grant Program Request for ProposalsJanuary 1, 2017 – September 30, 2019Information and Materials

May 2016

Community and Family Health Division Family Home Visiting SectionMaternal Infant Early Childhood Home Visiting (MIECHV) ApplicationP. O. Box 64882St. Paul, MN 55164-0882

Phone: 651-201-4090http://www.health.state.mn.us/fhv/

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Table of ContentsProgram Overview___________________________________________________________________5

Introduction______________________________________________________________________________5Definitions_______________________________________________________________________________6

Program Description_________________________________________________________________9

Background_______________________________________________________________________________9Purpose of the Funding_____________________________________________________________________9Models_________________________________________________________________________________10MDH Responsibilities______________________________________________________________________12Available Funding_________________________________________________________________________12Application Components___________________________________________________________________13Application Submission Guidance____________________________________________________________13Application Review and Award Process________________________________________________________13

Program Summary__________________________________________________________________15

Project Narrative and Work Plan______________________________________________________16

A. Applicant Information_________________________________________________________________16B. Linkages and Collaboration_____________________________________________________________16C. Subcontracts________________________________________________________________________17D. Statement of Need: Proposed High Need Area and Families to be Served________________________17E. Continuous Quality Improvement (CQI)___________________________________________________17F. Evaluation/Data Collection_____________________________________________________________18G. Model Selection and Target Caseload____________________________________________________19H. Implementation Plan_________________________________________________________________20I. Work Plan: Goals, Objectives, and Strategies______________________________________________20J. Need for Technical Assistance__________________________________________________________20

Budget Section_____________________________________________________________________21

Forms and Instructions______________________________________________________________23

Form A: Grant Applicant Face Sheet__________________________________________________________24Form B: Grant Application Checklist__________________________________________________________25Form C: Home Visitor Staffing Plan___________________________________________________________26Form D: MIECHV Work Plan (2017 – 2019)_____________________________________________________27Budget Justification Instructions_____________________________________________________________29Form E: Budget Justification Form____________________________________________________________33Budget Summary Instructions_______________________________________________________________35Form F: Budget Summary Form______________________________________________________________36Indirect Cost Questionnaire Instructions_______________________________________________________37Form G: Indirect Cost Questionnaire__________________________________________________________38

Appendices________________________________________________________________________39

Appendix A: Evidence-Based Home Visiting Model Descriptions____________________________________40Appendix B: Criteria for Scoring MIECHV Grant Applications_______________________________________44Appendix C: MIECHV Work Plan Example – 2017-2019 Grant RFP___________________________________48Appendix D: Expansion Information Form______________________________________________________51

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Appendix E: Average MIECHV target caseload served by current grantees during Calendar Year 2015______52Appendix F: High Risk Communities Identified in the Statewide Needs Assessment_____________________53Appendix G: Minnesota Department of Health Grant Agreement Sample_____________________________54Appendix H: Unallowable Uses of MDH Grant Funds_____________________________________________55

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Program OverviewIntroductionThis Request for Proposal (RFP) document provides the forms and information needed to complete the Maternal Infant Early Childhood Home Visiting (MIECHV) grant application. These documents are available on the Minnesota Department of Health (MDH) Family Home Visiting (FHV) website.

MDH will be available to provide consultation and guidance during the application process. All questions or requests for assistance should be submitted to Health.FHVGrants@state.mn.us. MDH Family Home Visiting staff should not be directedly contacted with questions or requests for assistance related to the application. MDH staff will not be able to help with writing the application.

MDH will maintain an “Answers to Grant Application Questions” link on the Family Home Visiting (FHV) website. Questions and Answers will be updated regularly before the application deadline.

There will be a technical assistance webinar to assist in writing the application. Applicants do not need to attend the webinar to submit an application. However, if applicants have questions about the grant application, they are encouraged to participate. The technical assistance webinar will include:

General information on the grant application General information on expectations related to the grant Information related to:

o Healthy Families Americao Nurse-Family Partnershipo Family Spirit

The webinar will use WebEx technology. Participants will need an internet connection, computer, and a phone line to access the audio portion of the webinar. The technical assistance webinar will be held on Thursday, May 26, 2016 from 1:30 to 3:30 p.m. To participate in the webinar click here.

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DefinitionsThe following definitions are used throughout this application:

Adaptations to Evidence-Based Home Visiting Models – Acceptable adaptations to an evidence-based home visiting model includes changes to the model that have not been tested with rigorous impact research but are determined by the Model Developer not to alter the core components related to program impacts. The Model Developer or its designee and MDH must approve any proposed adaptations.

Community Health Board (CHB)– The community health board as defined by Minnesota Statute 145A.02 is the legal governing authority for local public health in Minnesota. Community health boards work with MDH in partnership to prevent diseases, protect against environmental hazards, promote healthy behaviors and healthy communities, respond to disasters, ensure access to health services, and assure an adequate local public health infrastructure.

Continuous Quality Improvement (CQI) – A systematic approach to specifying the processes and outcomes of a program or set of practices through regular data collection and the application of changes that may lead to improvements in performance.

Contiguous – Geographic areas sharing a common border.

Eligible Family – Under the MIECHV authorizing legislation, an eligible family is (a) a woman who is pregnant, and the father of the child if the father is available; or (b) a parent or primary caregiver of a child, including grandparents or other relatives of the child, and foster parents, who are serving as the child’s primary caregiver from birth to kindergarten entry, and including a noncustodial parent who has an ongoing relationship with and at times provides physical care for the child.

Evidence-based Home Visiting Model – A home visitation model that has been in existence for at least three years and is research-based, grounded in relevant empirically-based knowledge, linked to program determined outcomes, associated with a national organization or institution of higher education that has comprehensive home visitation program standards that ensure high quality services delivery and continuous program improvement, and has demonstrated significant, positive outcomes on indicators described in federal legislation, when evaluated using a well-designed and rigorous randomized controlled research design and/or quasiexperimental research design, and the results of which have been published in a peer reviewed journal. Information on the three models eligible for funding under this application is available in Appendix A.

Family Home Visiting Reporting and Evaluation System (FHVRES) – The data collectionsystem developed for the collection of Minnesota’s family home visiting data and MIECHV performance measure data.

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High Risk Community – Counties were identified as high risk by Minnesota’s needs assessment. For this application, 46 high risk communities (counties) were identified. These high risk communities had a composite score of 13 or higher in the statewide needs assessment. See Appendix F for more information about the statewide needs assessment and the 46 eligible high risk communities.

High-Risk Priority Populations – Eligible populations identified in federal legislation as priority for receipt of MIECHV-funded home visiting services, including: families who reside in communities identified as at-risk communites in the statewide needs assessment; low-income families; pregnant women who have not attained age 21; families with a history of substance abuse or need for substance abuse treatment; families that have users of tobacco products in the home; families that are or have children with low student achievement; families that include individuals who are serving or formerly served in the Armed Forces, or who have had multiple deployments outside of the United States.

Home Visiting Models– Programs or initiatives in which home visiting is a primary servicedelivery strategy and in which services are offered on a voluntary basis to pregnant women,expectant fathers, and parents and caregivers of children birth to kindergarten entry, targetingMIECHV-adopted participant outcomes. For the purposes of this application, the following home visiting models are eligible for funding: Healthy Families America, Nurse-Family Partnership, and Family Spirit. Information on these models and the model developers is available in Appendix A.

HRSA – Health Resources and Services Administration, U.S. Department of Health & HumanServices.

Informed Consent – Written permission from an individual to allow a government entity to release the individual’s private data to another government or non-government entity or person, or to use the individual’s private data within the entity in a different way (Minnesota Statutes, section 13.05, subd. 4). A valid informed consent must be voluntary and not coerced, be in writing, and explain why the use or release of data is necessary. Awarded applicants must have a process that asks clients for their written informed consent to provide MDH with their identifiable individual level data for the purpose of evaluating the MIECHV program. Awarded applicants must inform their clients that the client’s decision regarding informed consent will not in any way impact that family’s access to services.

Maintaining Fidelity of a Model – Providing services which meet the specified criteria andcomponents of the identified evidence-based home visiting model on an on-going basis.

MIECHV – Maternal, Infant, and Early Childhood Home Visiting.

National model developer – Entity responsible for the development of an identified evidence-based home visiting model.

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Performance Measure Data – MIECHV performance reporting requirements include demographic, service utilization, and federally-mandated benchmark area performance measures. All awarded applicants will be required to collect performance measure data on participating families, and enter or upload the data into Minnesota’s Family Home Visiting Reporting and Evaluation System (FHVRES) or other data collection system designated by MDH. HRSA has recently revised the MIECHV performance reporting requirements, effective October 1, 2016. The required demographic and benchmark performance measures can be found on this website HRSA 2017 Performance Measures .

Reflective Supervision – Reflective supervision is a distinctive form of competency-based professional development that is provided to multidisciplinary early childhood home visitors who are working to support very young children’s primary caregiving relationships. Reflective supervision is a practice which acknowledges that very young children have unique developmental and relational needs and that all early learning occurs in the context of relationships. Reflective supervision is distinct from administrative supervision and clinical supervision due to the shared exploration of the parallel process, that is, attention to all of the relationships is important, including the relationships between home visitor and supervisor, between home visitor and parent, and between parent and infant/toddler. Reflective supervision supports professional and personal development of home visitors by attending to the emotional content of their work and how reactions to the content affect their work. In reflective supervision, there is often greater emphasis on the supervisor’s ability to listen and wait, allowing the supervisee to discover solutions, concepts and perceptions on his/her own without interruption from the supervisor.

Review Panel (RP) – A group of reviewers with backgrounds, knowledge and experience in maternal and child health, home visiting or early childhood development selected by MDH to evaluate and score submitted applications.

Target Caseload – The target caseload is the highest number of families (or households) that could potentially be enrolled at any given time if the program were operating with a full complement of hired and trained home visitiors. A trained home visitor must have at least 25 percent of his/her personnel costs (salary/wages including benefits) paid for with MIECHV funding to have families served be counted as part of the target caseload. All members of one family or household represent one caseload unit. Only active cases as defined by the evidence-based model may be counted toward the target caseload when reporting. The target caseload is distinguished from the cumulative number of familes enrolled through the grant period. Awarded applicants will identify a target caseload that will be achieved and maintained throughout the grant agreement.

Title V – Enacted in 1935 as part of the federal Social Security Act, the Title V Maternal and Child Health Program is designed to help states ensure the health of the Nation’s mothers, women, children and youth, including children with special health care needs, and their families.

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Tribal Nation – A federally recognized American Indian tribe considered a sovereign nation.

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Program DescriptionBackgroundThe Maternal Infant Early Childhood Home Visiting (MIECHV) funds originally authorized in the federal Affordable Care Act (ACA) are administered through a partnership between the Health Resources and Services Administration (HRSA) and the Administration for Children and Families (ACF) of the U.S. Department of Health and Human Services. Funding allows states, territories and tribal entities to develop and implement voluntary, evidence-based home visiting prorams using models that are proven to improve child health and to be cost effective. These programs improve maternal and child health, prevent child abuse and negelect, encourage positive parenting, and promote child development and school readiness.

Purpose of the FundingThe purpose of this funding is for applicants to implement an evidence-based home visiting model or to expand an existing evidence-based model based on identified community need. The evidence-based home visiting models that can be chosen for implementation or expansion are Nurse-Family Partnership (NFP), Healthy Families America (HFA), and Family Spirit (FS). Community Health Boards or Tribal Nations serving families in identified high risk communities in Minnesota are eligible applicants (Appendix F). The models are intended to be implemented at the community level as part of a coordinated, integrated system of early childhood services.

Goals for the funding include: To strengthen and improve the state’s programs and activities carried out under Title V To improve coordination of services for high risk communities To identify and provide comprehensive services to improve outcomes for families who

reside in high risk communities

Funding is to support Community Health Boards and Tribal Nations in identified high risk communities (a list of high risk communities is attached as Appendix F) to:

Implement or expand an existing home visiting model(s)o Nurse-Family Partnership (NFP)o Healthy Families America (HFA)o Family Spirit (FS)

Serve eligible high-risk families Voluntarily enroll eligible families and maintain an identified target caseload Collect and report MIECHV performance measure data in the manner identified by the

MDH Maintain model fidelity for the chosen model(s) Participate in required trainings, meetings, continuous quality improvement and

evaluation activities including participation in communities of practice Collaborate with community partners to assure a coordinated, effective early childhood

system in the community and avoid duplication of services to families

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Implement reflective practice supervision and infant mental health consultation including entering into contracts with infant mental health consultants that will support monthly team case conferencing, supervisor participation in monthly reflective practice consultation and additional consultation as needed

Follow state guidance on development of program policies regarding enrollment, disengagement, and re-enrollment of eligible families as well as other program policies that may be identified by MDH for development and/or implementation

Counties not designated as a high risk community may collaborate with continguous high risk designated counties. A justification for the selected contiguous multi-county area must be provided and the designated area must be a viable and feasible area for providing services.

Priority will be given to applicants who propose to serve: Eligible families who reside in communities in need of such services, as identified in the

statewide needs assessment Low-income eligible families Eligible families with pregnant women who have not attained age 21 Eligible families that have a history of child abuse or neglect or have had interactions

with child welfare services Eligible families that have a history of substance abuse or need substance abuse

treatment Eligible families that have users of tobacco products in the home Eligible families that are or have children with low student achievement Eligible families with children with developmental delays or disabilities Eligible families that include individuals who are serving or formerly served in the Armed

Forces, including such families that have members of the Armed Forces who have had multiple deployments outside of the United States

ModelsBelow is a brief description of the models to be considered by applicants and to be funded by this application.

Nurse-Family PartnershipNFP is an evidence-based, community health program that helps transform the lives of vulnerable mothers pregnant with their first child. Each mother served by NFP is partnered with a registered nurse early in her pregnancy and receives ongoing nurse home visits that continue through her child’s second birthday. Independent research proves that communities benefit from this relationship — every dollar invested in NFP can yield more than five dollars in return.

Nurse-Family Partnership Goals:1. Improve pregnancy outcomes by helping women engage in preventive health practices,

including prenatal care from their healthcare providers, improving diets and reducing use of cigarettes, alcohol and illegal substances;

2. Improve child health and development by helping parents provide responsible and competent care; and,

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3. Improve the economic self-sufficiency of the family by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find work.

For information about becoming a new NFP replication site in Minnesota contact Chelsea Pearsall, MA, Business Development Manager at chelsea.pearsall@nursefamilypartnership.org

For information about expanding a current NFP program in Minnesota contact Amy Goodhue, PHN, Nurse Consultant at amy.goodhue@nursefamilypartnership.org

Healthy Families AmericaHealthy Families America (HFA) is an evidence-based intensive home visiting program designed for parents facing challenges such as single parenthood; low income; childhood history of abuse and other adverse child experiences; and current or previous issues related to substance abuse, mental health issues, and/or domestic violence. Interactions between direct service providers and families are relationship-based, designed to promote positive parent-child relationships and healthy attachment, strength-based, family centered, culturally sensitive and reflective.

Individual HFA sites select the specific characteristics of families they plan to serve and collaborate with community partners to reach these families. All families complete a Parent Survey or similar assessment in order to determine the presence of various factors associated with increased risk for child maltreatment or other adverse childhood experiences, as well as identify family strengths and protective factors.

HFA aims to: 1. reduce child maltreatment;2. improve parent-child interactions and children’s social-emotional well-being;3. increase school readiness;4. promote child physical health and development;5. promote positive parenting;6. promote family self-sufficiency;7. increase access to primary care medical services and community services; and8. decrease child injuries and emergency department use.

For information more information about HFA you can email the Implementaion Specialist for Minnesota, Christi Peeples, at cpeeples@preventchildabuse.org, or the National Director of Implementation and Accreditation, Kathleen Strader, at kstrader@preventchildabuse.org. Additional information about HFA is available at the HFA website.

Family SpiritFamily Spirit is an evidence-based family home visiting program designed by and for American Indian pregnant women and families with children to age three. Family Spirit combines the use of paraprofessionals, as well as nurses and other professionals, from the community as home visitors and a culturally focused, strengths-based curriculum as a core strategy to support young families. Parents gain knowledge and skills to promote healthy development and positive lifestyles for themselves and their children. This program has been developed, implemented,

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and evaluated by the Johns Hopkins Center for American Indian Health in partnership with the Navajo, White Mountain Apache, and San Carlos Apache Tribes since 1995.

Each agency implementing Family Spirit will complete a replication assessment with Johns Hopkins and are free to determine their specific target audience and how the program will be utilized in their community.

Family Spirit Program Goals:1. To address the behavioral health disparities that pose the greatest challenges to Native

communities;2. Increase parent knowledge and self-efficacy;3. Address and decrease maternal depression;4. Decrease substance use; and,5. Address behavior problems in children with a unique curriculum.

For more information about Family Spirit you can email familyspirit@jhu.edu or call Crystal Kee (928-674-3911) or Jennifer Richards (928-283-8221). Additional information is available at the Family Spirit website.

Additional information related to the models listed above, including initial costs and frequency of visits, is included in Appendix A.

MDH ResponsibilitiesThe MDH Family Home Visiting Section will:

1. Provide guidance and consultation as needed for the performance of the project and maintaining fidelity to MIECHV and home visiting model requirements, including but not limited to site visits, conference calls, and meetings or communities of practice.

2. Provide reporting requirements and tools for quarterly or annual reports.3. Provide training and technical assistance on the MIECHV project, policies and

procedures, data collection procedures, forms, measures, continuous quality improvement, and project evaluation.

4. Provide training, access, and technical assistance for the Family Home Visiting Reporting and Evaluation System (FHVRES) or other designated data collection system.

Available FundingGrant awards are for 33 months (1/1/17 through 9/30/19). MDH anticipates awarding 12 grants.

Current MIECHV grantees may only apply for funding to serve the average MIECHV target caseload they reported to MDH in 2015. Appendix E contains information regarding the average MIECHV target caseload served at each site during 2015 based on quarterly data submitted to MDH.

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Applicants proposing to implement a model that has not been previously implemented by the applicant may only apply for funding to serve up to 100 families for sites proposing NFP or Family Spirit implementation and up to 96 families for sites proposing to implement HFA utilizing the ratio of families to FTE home visitors recommended by the model developer as follows:

Nurse Family Partnership: 100 families with four FTE home visitors Healthy Families America: 48 families with two FTE home visitors Family Spirit: 25 families with one FTE home visitor

Applicants who have not been MIECHV grantees and who have implemented an evidence-based model or provided long term intensive home visiting may apply for the average number of families that were served through the implemented model(s) or long term intensive home visiting program in 2015.

Awarded applicants should not use funds from this funding opportunity to replace existing funds for evidence-based home visiting programs in the applicant area. Awarded applicants are expected to sustain current funding levels for existing evidence-based home visiting programs.

Application ComponentsSee Form B, Grant Application Checklist for application components that should be submitted with the application.

Application Submission Guidance Narrative portions of the application should be written in 12-point font, single spaced

with one-inch margins. The Work Plan (Form D) can be in 11 point font. All pages should be numbered consecutively. Click here to access a brief survey that must be completed by each applicant. Submit the entire application as one PDF document including the forms in the order

listed on Form B Grant Application Checklist Form by email to: Health.FHVGrants@state.mn.us.

The deadline for submission of applications is 4:00 p.m. on Friday, July 15, 2016. No application will be accepted for consideration after this time.

Application Review and Award ProcessThis is a competitive grant application. Applications will be reviewed and scored according to the Criteria for Scoring MIECHV Grant Applications (Appendix B). An applicant’s past performance in implementing an evidence-based home visiting model and/or MIECHV grant will be taken into consideration during the review process and in making final recommendations for funding.

Reviewers may include staff from the MDH, developers of evidence-based home visiting models or their staff, and staff from state agencies with experience related to early childhood or family services, or individuals who are familiar with or who have provided home visiting services.

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Reviewers will be required to identify any conflicts of interest and will not review an application if they have a direct relationship with the applicant.

Final funding recommendations will be based on the scores and comments from reviewers, past performance of current funded MIECHV grantees and the high risk rankings identified in the Minnesota needs assessment. When making awards, consideration will be given to distributing funding throughout the state and/or regions and meeting the funding priorities identified in the MIECHV legislation and MDH’s federal MIECHV application. It is anticipated that grant award decisions will be made in September 2016. Applicants will be notified whether or not their grant application was funded.

All materials submitted in response to this RFP will become property of the State and will become public record in accordance with Minnesota Statutes, section 13.599 after the evaluation process is completed. Pursuant to the statute, completion of the evaluation process occurs when the government entity has completed negotiating the grant agreement with the selected grantee. If the applicant submits information in response to this application that it believes to be trade secret materials, as defined by the Minnesota Government Data Practices Act, Minnesota Statute §13.37, the applicant must: Clearly mark all trade secret materials in its response at the time the application is

submitted; Include a statement with its application justifying the trade secret designation for each

item; and, Defend any action seeking release of the materials it believes to be trade secret, and

indemnify and hold harmless the State, its agents and employees, from any judgements or damages awarded against the State in favor of the party requesting the materials, and any and all costs connected with that defense. This indemnification survives the State’s award of a grant contract. In submitting a response to this application, the applicant agrees that this indemnification survives as long as the trade secret materials are in possession of the State.

Applications are nonpublic until opened. Once opened, the name of the applicant, the address of the applicant, and the amount the applicant requested is public. All other data in an application is nonpublic data until completion of the evaluation process. After the evaluation process has been completed, all data submitted by the applicant is public.

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Program Summary

Eligibility for Grant Funds Community Health Boards, Tribal Nations

Total Funds Available $5,500,000.00 for period January 1, 2017 – September 30, 2019

Grant Cycle January 1, 2017 through September 30, 2019

Grant Purpose To implement or expand an existing evidence-based home visting model(s).

Application Guidance To participate in the technical assistance webinar on Thursday, May 26 from

1:30 – 3:30 p.m. click here. Participation is not required, but encouraged. Narrative portions should be in at least 12-point font with one-inch margins All pages should be numbered consecutively This brief survey must be completed by each applicant One PDF document submitted electronically to

Health.FHVgrants@state.mn.us

Application Deadline All applications must be received electronically by MDH no later than 4:00 p.m. (CST) on Friday, July 15, 2016.

Late applications will not be considered for review.

Applications Sent: Electronic Delivery Address: Health.FHVGrants@state.mn.us

Beginning Grant Agreement Date

January 1, 2017, or date upon which all signatures to the agreement are obtained, whichever is later.

AuthorityThe Minnesota Department of Health is the recipient of funding from the U. S. Department of Health & Human Services to implement Minnesota’s Maternal Infant and Early Childhood Home Visiting (MIECHV) Initiative (HRSA Grant No. X10MC29483). This program is authorized under the Social Security Act, Title V, Section 511 (42 USC 711), as amended by Section 2951 of the Patient Protection and Affordable Care Act (Pub. L. No. 111-148).

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Project Narrative and Work PlanThe project narrative and work plan describes the applicant’s organization and what is intended to be accomplished. To assist applicants, MDH has provided detailed instructions on what information should be included and what grant reviewers will be reviewing in each application.

The Project Narrative is divided into distinct sections and should be submitted in the sequence below:

A. Applicant InformationB. Linkages and CollaborationC. SubcontractsD. Statement of Need: Proposed High Need Area and Families to be ServedE. Continuous Quality ImprovementF. Evaluation/Data CollectionG. Model Selection and Target CaseloadH. Implementation PlanI. Work Plan: Goals, Objectives, and Strategies (Form D)J. Need for Technical Assistance

A. Applicant InformationPlease keep this section to two or fewer pages.If an applicant submits a joint application, the limit is two pages per organization. Applicants should use 12-point font with one-inch margins for this portion.

1. Briefly summarize the applicant’s history related to family home visiting and if applicable, experience implementing an evidence-based home visiting model.

2. Identify the local resources that are available to support or enhance the efforts of the proposed application activities. Resources may include community achievements; strengths; experience; commitment; staff; interagency experience or cooperation on infrastructure tasks such as coordinated intake, screening and referral of families.

3. Briefly describe the support the applicant has related to this grant application including applicant or governing body support.

4. Briefly describe the applicant’s history, success and capacity to bill for home visiting services.

B. Linkages and CollaborationPlease keep this section to two or fewer pages.

1. Please describe the applicant’s collaboration with community partners related to planning for or implementation of the evidence based model(s).

2. Please describe any proposed or current regional partnerships including discussions that have occurred.

3. Discuss other home visiting programs (e.g. Early Head Start) in the community and how applicant will assure non-duplication of home visiting services and coordination of home visiting services in the community.

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4. Discuss how implementation or expansion of the evidence-based home visiting model(s) will enhance and be integrated into the local early childhood system.

5. Describe the community advisory board that will be used to support the implementation of the evidence-based home visiting model(s). Include information about members of the community advisory board (community partners, funders, families who have received home visiting, etc.), the role of the advisory board in the program, and frequency of meetings.

C. SubcontractsPlease keep this section to one page or less.All applicants must identify any subcontracts that will be required to carry out the duties stated in the application in the Contractual Services line of the proposed Budget Section. The use of subcontracts is subject to MDH review and may change based on final work plan and budget negotiations with awarded applicants.

1. Describe services to be subcontracted.2. Provide anticipated subcontractor/consultant’s name (if known) or selection process to be

used.3. Estimate length of time services will be provided.4. Total amount to be paid to subcontractor.

D. Statement of Need: Proposed High Need Area and Families to be Served Please keep this section to two or fewer pages.Please describe the need that the applicant is addressing in the community as the applicant plans for implementation or expansion of the evidence-based home visiting model(s). Include information about:

1. target population;2. any needs assessment that was completed by the applicant independently or in

collaboration with other community partners;3. identification of, rationale for proposing and feasibility to serve a county contiguous to the

high risk community and not identified as high risk for this application; and,4. waiting list for sites considering expansion.

Include results or information from any planning process or tool such as the Zero to Three Home Visiting Community Planning Tool that were used to determine the need and capacity for the proposed implementation or expansion of the evidence-based home visiting model(s) in the community.

E. Continuous Quality Improvement (CQI)Please keep this section to two or fewer pages.Applicants will be required to participate in a CQI learning collaborative and to develop their own CQI projects related to implementation of their chosen model or connecting with the early childhood system in their community. Meetings will be held quarterly via webinar/phone. Each awarded applicant will be required to have a team of at least two to three people (including a

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supervisor and a home visitor) participate. Each awarded applicant will be required to actively implement, track, and report on CQI projects related to home visiting.

1. Describe experience with quality assurance in general and any experience with the quality assurance required by the proposed evidence-based home visiting model(s).

2. Describe any barriers or challenges to conducting CQI activities and any strategies for addressing those barriers or challenges.

3. Describe how staff time will be budgeted and supported to focus on continuous improvement.

4. Describe what data systems are available for use by the applicant for CQI purposes, and how those data systems would be used to track progress, measure whether change ideas resulted in improvement, identify the need for course corrections, and use data to drive decision-making.

F. Evaluation/Data CollectionPlease keep this section to two or fewer pages.Awarded applicants will be required to submit data to FHVRES or other data collection systems identified by MDH. Because of recent changes made by HRSA to the MIECHV performance measures, MDH will need to implement changes to its current data collection system. It is expected that there will be a six to twelve month transition period, during which alternative methods of data submission may be required, such as the use of temporary data collection forms or direct entry into a data collection system designated by MDH. Applicants should allocate sufficient funds in their budget to support changes to the collection and reporting of performance measure data, as well as staff time for alternative methods of data submission during the transition period.

1. Describe the applicant’s ability to collect and report performance measure data as required by federal, state, and model guidance. List any local data systems that will be used for the collection of data.

2. If the applicant plans to make arrangements with another organization or government entity to report performance measure data to MDH on the applicant’s behalf, please state this and describe how the applicant will ensure that performance measure data will be submitted as required. This may include duties in subcontracts as described in Section C above.

3. Describe the applicant’s current frequency of data collection and analysis.4. Describe the applicant’s experience ensuring the quality of data collection, and with

data management and analysis.5. Describe the applicant’s data safety and security processes monitoring including

protection of data privacy and informed consent policies and procedures.6. Describe any barriers or challenges to performance measure data collection and

reporting, and possible strategies for addressing those challenges.

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G. Model Selection and Target CaseloadPlease keep this section to two or fewer pages

1. Identify the model(s) the applicant proposes to implement or expand.2. Describe how the selected model(s) address the high risk community and high risk

target population.3. Describe how the proposed model(s) meets the needs or fills gaps of the community’s

home visiting continuum, including plans to ensure non-duplication of home visiting services.

4. Describe the applicant’s capacity and readiness to implement the proposed model(s) including capacity to hire and train staff.

5. Describe interactions with model developer(s) related to the proposed activities outlined in this application, including any documents that may have been submitted to a model developer as part of their recommended or required process for implementation or expansion, and any feedback that was received from the model developer.

6. Identify any challenges and risks of implementing the proposed model(s), any challenges and risks in maintaining quality and fidelity to the model, any proposed resolutions to those challenges and risks.

7. Identify the target caseload for each proposed evidence-based model that will be achieved and maintained at 85% or higher under this proposed application, and how the target caseload was determined. Note that only active cases as defined by the evidence-based model may be counted toward the target caseload. If funded previously with MIECHV funding, describe the success in achieving and maintaining the target caseload for each year funded. CURRENT MIECHV GRANTEES: Please note the average target caseload reported to MDH for 2015 provided in Appendix E. If you are requesting to serve a target caseload in this application above the average reported to MDH in 2015 or if you believe that your average caseload was greater than what is included in Appendix E, please indicate the rationale for submitting a target caseload in this application greater than the 2015 average. You should include information about changes the applicant is making to their data collection and reporting submitted to MDH to assure accurate data reporting. NON-MIECHV APPLICANTS CURRENTLY IMPLEMENTING AN EVIDENCE-BASED MODEL OR PROVIDING LONG TERM, INTENSIVE HOME VISITING: Applicants must provide the average number of families served through an evidence-based model or applicant’s long term, intensive home visiting program for 2015 and the number of FTEs serving those models and/or programs.

8. Describe challenges or barriers that may be or were experienced in achieving and maintaining a minimum of 85% of the target caseload. Describe plans for addressing and overcoming those challenges.

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H. Implementation PlanPlease keep this section to two or fewer pages

1. Describe the plan for recruiting, hiring, training and retaining appropriate staff for positions associated with the activities proposed in this application.

2. Evidence-based home visiting models identify the importance of a home visitor implementing a model being at least .5 FTE in the model. This supports the home visitor in implementing the model with fidelity and retaining families contributing to the overall success of the program. Please complete Staffing Plan Form C. For each home visitor that will be involved in implementing the activities outlined in this grant application, include information about the total FTE the staff is involved in model implementation whether funded by this proposed application or other funding sources.

3. Describe the plan for providing high quality reflective practice for all home visitors and supervisors including infant mental health consultation and challenges and resolutions that may be encountered in providing high quality reflective practice for all home visitors and supervisors.

4. Describe the plan for identifying and recruiting high risk families to be served under this application, including a plan for minimizing the attrition rate for participants.

5. Provide the estimated timeline to reach and maintain the target caseload.6. Describe a plan for how the proposed model(s) will be implemented with fidelity to the

model, and any anticipated challenges to implementing the model(s) with fidelity, including potential activities that would minimize those challenges.

7. Describe the process and commitment for development of a policy related to enrollment, disengagement and re-enrollment, and non-duplication of services that awarded applicants will be required to develop.

8. Describe the referral network that will be utilized to implement this program. Include information both on resources that will refer families to the program and resources that families will be referred to for needed services.

I. Work Plan: Goals, Objectives, and StrategiesComplete all of the work plan (Form D). Please limit the entire work plan to two or fewer pages.The work plan has objectives that should not be changed. The dates included in the objectives are suggestions and the dates may be changed according to the specific applicant’s timeline. Note: If the application is approved and funded at the level requested, the Work Plan (Form D) will be incorporated into the grant agreement between MDH and the grantee applicant as contractor’s duties. A Work Plan must be completed according to directions so they can be separated easily from the rest of the application. (See Appendix C for a Work Plan example.)

J. Need for Technical AssistancePlease keep this section to two or fewer pages.Please describe any anticipated need for technical assistance or training and availability of resources that can provide needed technical assistance and training. Applicants should identify the anticipated number of staff that will need to participate in trainings sponsored by MDH and identify the training needed, i.e. three staff need GGK training, two staff need NCAST.

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Budget SectionBefore writing the budget, consider the specific activity planned and the resources (staffing, supplies, equipment, etc.) needed. Which resources are already available and what resources need to be purchased? Which items will need to be replaced during the program (grant time period)? When considering the skills needed to carry out the grant activity, including the financial aspect of the grant, remember to include any training that will be needed for paid staff or volunteer members.

Applicants proposing activities that involve the distribution of incentives for program participation must include the costs for purchasing any incentives in the “Other” line of the budget and follow the guidelines stated below.

Incentives can include gift cards or specific items. They may only be given to eligible participants who:

Attended a meeting/session/conference where the primary purpose of which is the dissemination of grant program information.

Completed a health screening or test; Participated in a public health study or survey; Participated in a one-time event designed to improve the public health or health care

systems by:o Providing first-hand experience as a recipient of health care or public health services,

or o as a child or adolescent model for trainings.

A participant may not receive more than $50 worth of incentives per year. If using gift cards, or a combination of gift cards and specific items, the total combined value may not exceed $50.00.

Incentives must be kept in a secure locked location at all times (ex: locked drawer, locked cabinet).

The applicant/grantee must track which client/participant received the incentive and the dollar value of that incentive. Applicants/grantees must ensure data privacy when tracking the distribution of incentives.

Incentives must be distributed in the funding year in which they are purchased. In order for the expense of purchasing incentives to be reimbursable, the applicant must:

o address the use of incentives in the text of the RFP applicationo account for the incentives in the “Other” line of the budget justificationo obtain MDH’s approval of the budget justification that includes the incentives

The applicant will need to complete one Budget Justification Form AND one Budget Summary Form for each time period of applicant’s grant program listed below:

January 1, 2017 – September 30, 2017 October 1, 2017 – September 30, 2018October 1, 2018 – September 30, 2019

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Budget Justification Instructions and Form (Form E)Please read the instructions for the Budget Justification Form carefully before completing the Budget Justification Form. For each line item on the budget, provide a rationale and details relative to how the budgeted cost items were calculated.

Each Budget Justification Form should provide the details of the applicant’s expenses and a brief description of how they support the proposed grant activity for that time period. (The full description of the purpose of each grant-funded position and the necessity of budgeted items should appear in the Project Narrative.)

Budget Summary Instructions and Form (Form F)Please read the instructions for the Budget Summary Form carefully before completing the Budget Summary Form. Expenses in the line items should match the amounts listed in the line items on the corresponding Budget Justification Form.

Each Budget Summary should be where the applicant provides the total expenses for the time periods of the proposal by adding the expenses from the Budget Justification Form.

Indirect Cost Questionnaire (Form G)Complete Form G. If the applicant will be using a Federally Negotiated Indirect Cost Rate, include copy of the most recent Federally Negotiated Indirect Cost Rate with Form G.

Budget ScoringThe scoring of the Budget Section will be done using the Budget Justification Form and the Budget Summary Form. If supplementary information is included, it will not be taken into consideration for scoring purposes.

REMINDERS: Provide one Budget Justification Form AND one Budget Summary Form for each time

period listed below:January 1, 2017 – September 30, 2017 October 1, 2017 – September 30, 2018October 1, 2018 – September 30, 2019

Total all lines and columns and check for mathematical accuracy. Make sure that the budget summary totals match the amount listed in number 1 on the

Grant Application Face Sheet (Form A).

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Forms and InstructionsA. Grant Application Face Sheet Form

B. Grant Application Checklist Form

C. Home Visitor Staffing Plan

D. MIECHV Work Plan Form

E. Budget Justification Instructions & Form (one form for each time period listed on p. 22)

F. Budget Summary Instructions & Form (one form for each time period listed on p. 22)

G. Indirect Cost Questionnaire Form

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Form A: Grant Applicant Face SheetGeneral Applicant Information

Applicant’s Legal Name (do not use a “doing business as” name):     

Applicant’s Business Address:      

Applicant’s Minnesota Tax Identification Number:      

Applicant’s Federal Tax Identification Number:      

SWIFT Vendor ID Number (if you hae one):      

Director of Applicant AgencyName:     

Business Address:      

Phone Number:      

Email:      

Financial Contact, or Fiscal Agent, for this grantName of Financial Contact for this grant:      

Name of Fiscal Agent for this grant, if applicable:      

Phone Number:      

Email:      

Contact Person for this grantName:      

Business Address:      

Phone Number:      

Email:      

Requested FundingTotal Amount on Proposed Budget: $     

I certify that the information contained above is true and accurate to the best of my knowledge; that I have informed this agency’s governing board of the agency’s intent to apply for this grant; and, that I have received approval from the governing board to submit this application on behalf of the agency.

Signature of Authorized Agent for Applicant

Date of signature

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Form B: Grant Application Checklist

Use this checklist to ensure that you have included all the items for the grant application.

Have you included the following items? Grant Applicant Face Sheet (Form A) Clicked here to access a brief survey that must be completed by each applicant. Grant Application Checklist (Form B) Home Visitor Staffing Plan (Form C) MIECHV Work Plan Form (Form D) Budget Justification Form (Form E) (one for each time period listed on p. 22) Budget Summary Form (Form F) (one for each time period listed on p. 22) Indirect Cost Questionnaire (Form G)

APPLICATION DEADLINE:Not later than 4:00 PM (CST) on Friday, July 15, 2016. Applications received after this time will not be reviewed.

Electronic Delivery Address: Health.FHVGrants@state.mn.us

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Form C: Home Visitor Staffing PlanTable C1 Home Visitor Staffing Plan

Home Visitor FTE in Proposed Application (Minimum of .25 FTE)

FTE in Implementing the Model in All Applicant’s Programs

Funding for Home Visitor (Bold or Underscore Funding Sources Used)

MIECHVNFP State FundsTANFTitle V/MCH BlockOtherMIECHVNFP State FundsTANFTitle V/MCH BlockOtherMIECHVNFP State FundsTANFTitle V/MCH BlockOtherMIECHVNFP State FundsTANFTitle V/MCH BlockOtherMIECHVNFP State FundsTANFTitle V/MCH BlockOtherMIECHVNFP State FundsTANFTitle V/MCH BlockOtherMIECHVNFP State FundsTANFTitle V/MCH BlockOther

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Form D: MIECHV Work Plan (2017 – 2019)

Community Health Board or Tribal Nation:

Counties Included in Application:

Contact Person for Work Plan including name, email, and phone no.:

Date Submitted:

Target Caseload for Model to be Implemented:

_____ Healthy Families America _______ Nurse-Family Partnership _______ Family Spirit

Income: Report total income from Medicaid and other health insurance. Income can only be used for allowable program costs. $_________________

Objectives Activities Quarterly ReportBy January 1, 2017 develop a referral network for incoming referrals to the program and resources that the program will refer families to based on need. By February 1, 2017 identify members of a CQI team and begin participation in the MIECHV CQI Learning Collaborative.By March 1, 2017 identify members and purpose of the community advisory board and implement utilization of the community advisory board to provide guidance for program implementation. By March 1, 2017 a plan will be developed identifying potential funding sources and next steps to provide program sustainability. By March 1, 2017 a plan will be developed and implemented for how reflective practice support will be provided for program

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Objectives Activities Quarterly Reportsupervisors and home visitors throughout the grant period. By April 15, 2017 and quarterly thereafter submit quarterly reports to MDH related to activities in this work plan. By April 15, 2017 and monthly thereafter submit data as outlined in the current version of the Family Home Visiting Reporting Guidance document for submission to MDH via the designated data reporting system. By May 1, 2017 develop policies as directed by MDH. Policies will include but not be limited to a policy assuring coordination of home visiting programs in the community and non-duplication of home visiting services. By January 1, 2017 for previously funded MIECHV sites and May 1, 2017 for new MIECHV sites achieve and maintain model approval, affiliation or accreditation and retain model fidelity through the grant period. By June 1, 2017, a plan with community partners will be developed that integrates home visiting into the early childhood system in the community and implement the plan throughout the remainder of the grant period. By May 1, 2017 for previously funded MIECHV sites and December 31, 2017 for new MIECHV sites achieve a full case load of families to be served and maintain the caseload at 85% during the grant period.

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Budget Justification InstructionsBefore the applicant begins writing the organization’s budget, consider the specific activity planned and the resources needed to do it. What resources does the applicant need to be able to plan for implementation or expansion of the proposed evidence-based home visiting model(s)? Which items will need to be replaced during the grant program? When considering the skills needed to carry out the activity, remember to include any training that will be needed for staff.

Applicant will need to complete Budget Justification Form (Form E), one for each time period of grant program listed on page 22. The Budget Summary Form (Form F) is where the applicant will summarize each period of the grant Budget Justification Form by line item for each time period of applicant’s grant proposal.

Each Budget Justification Form will provide the details of the applicant’s expenses and a brief description of how they support the proposed grant activity for that budget period. (A full description of how the applicant’s expenses support the proposed activities, including grant-funded positions, should appear in the Project Narrative.)

The categories listed below (salary/fringe, contractual services, travel, supplies/expenses, other, and indirect) describe the costs that may be included in each category and correspond to the sections in both the Budget Justification Form and the Budget Summary Form.

Salary and FringeFor each proposed funded position, indicate the title, the full time equivalent (FTE) on this grant (see example below), the expected rate of pay, and the total amount applicant expects to pay the position for the year. Grant funds can be used for salary and fringe benefits for staff members directly involved in applicant’s proposed activities.

Any salaries from the administrative, accounting, human resources, or IT support, MUST be supported by some type of time tracking, in order to be included as a direct line expense. If these salary expenses are not supported by time reporting documentation, then the expenses must be included in the Indirect line and listed on the Indirect Cost Questionnaire.

Full time equivalent (FTE): The percentage of time a person will work on the selected evidence-based home visiting model(s). Each position that will work on this grant should show the following information:

EXAMPLE:Public Health Nurse: $30.40/hourly rate

X 2,080/annual hours (or whatever your annual standard is)$63,232 annual salary

Multiply annual salary by your agency’s fringe rate:$63,232 annual salary

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X 23% fringe rate (23% is an example, use applicant fringe rate)$14,543 fringe amount

Now add the annual salary and the fringe amount together:$63,232 annual salary

+$14,543 fringe$77,775/annual salary and fringe total

Multiply the annual salary and fringe total by the FTE being charged to this grant:$77,775 annual salary and fringe totalX .50 FTE assigned to grant$38,888 total to be charged to grant for this position

Contractual ServicesApplicants must identify any subcontracts that will occur as part of carrying out the duties of this grant program as part of the Contractual Services budget line item in your proposed budget. The use of contractual services is subject to State review and may change based on final work plan and budget negotiations with selected grantees.

Applicant responses must include: Description of services to be contracted; Anticipated contractor/consultant’s name (if known) or selection process to be used; Length of time the services will be provided; and, Total amount to be paid to contractor.

TravelList the expected travel costs for staff working on the grant, including mileage, hotel, and meals. If project staff will travel during the course of their jobs or for attendance at educational events, itemize the costs, frequency, and the nature of the travel. Grant funds cannot be used for out-of-state travel without prior written approval from MDH. Minnesota will be considered the home state for determining whether travel is out of state.

Community Health Board applicants: Budget for travel costs using the rates listed in the State of Minnesota’s Commissioner’s

Plan. Please reference the meal allowances rates listed there. Hotel/motel expenses should be reasonable and consistent with the facilities available.

Grantees are expected to exercise good judgement when incurring lodging expenses. Mileage will be reimbursed at the current IRS rate.

Tribal Nation applicants:Budget for travel costs using the rates provided by the General Services Administration (GSA). Current lodging amounts and meal reimbursement rates vary depending on where in

Minnesota the travel occurs. Please reference the per diem rates listed there.

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Hotel/motel expenses should be reasonable and consistent with the facilities available. Grantees are expected to exercise good judgement when incurring lodging expenses.

A breakdown of the meals and incidental expenses can be found here. Mileage will be reimbursed at the current IRS rate.

Supplies and ExpensesBriefly explain the expected costs for items and services the applicant will purchase to run the program. These might include additional telephone equipment; postage; printing; photocopying; office supplies; training materials; and equipment. Include the costs expected to be incurred to ensure that community representatives, partners, or clients who are included in the applicant’s process or program can participate fully. Examples of these costs are fees paid to translators or interpreters. Grant funds may not be used to purchase any individual piece of equipment that costs more than $5,000, or for major capital improvements to property. Supplies and expenses should represent the appropriate fair share to the grant.

OtherInclude in this section any expenses the applicant expects to have for other items that do not fit in any other category. Some examples include, but are not limited to: staff training and incentives. Grant funds cannot be used for capital purchases, permanent improvements; cash assistance paid directly to individuals; or any cost not directly related to the grant. “Other” expenses should represent the appropriate fair share to the grant.

Indirect CostsIndirect costs are expenses of doing business that cannot be directly attributed to a specific grant program or budget line item. These costs are often allocated across an entire agency and may include administrative, executive and/or supervisory salaries and fringe, rent, facilities maintenance, insurance premiums, etc.

The following are examples that could be included in indirect costs: Your department pays a general percentage to the city/county attorney’s office or the

sheriff’s department and these costs cannot be specifically attributed to an individual grant.

Your CHB or department pays a fee or percentage to the county/city human resources department and these costs are not tied to a specific grant.

The CHBs accounting system does not allow community health services (CHS) administrator’s time to be directly attributed to specific grant activities.

In contrast, administrative costs are expenses not directly related to delivering grant objectives, but necessary to support a particular grant program. These are items that, while general expenses, can be attributed and appropriately tracked to specific awards. These items should be included in the grantee budget as direct expenses in the appropriate lines of Salaries and Fringe, Supplies, Contractual Services, or Other. They should not be included in the Indirect line.

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The following are examples of administrative costs that should be included in direct lines of the budget and/or invoice:

The CHS administrator’s time that can be tracked through time studies to a specific grant (include in the Salary/Fringe line).

A portion of secretarial/administrative support, accounting, human resources or IT support staff expenses that can be tracked through time studies to a specific grant (include in the Salary/Fringe line).

Printing and supplies that your accounting system is able to track (for example through copy codes) to a specific grant (include in the Supply line).

Any salary costs included in the Salary and Fringe line of the budget and/or invoice must be if supported by proper time documentation. The total allowed for indirect costs can be charges up to your federally approved indirect rate, or up to a maximum of 10%.

If the applicant will be using a Federally Negotiated Indirect Cost Rate, you will need to submit with your application your most current federally approved indirect rate.

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Form E: Budget Justification FormComplete one form for each time period listed on page 22.MDH Grant Program Name:Applicant Agency:Contact Person:Phone Number:Email Address:Budget Period: ________ to ________

Revision # (MDH use only):

1. Salary and Fringe Benefits: For each proposed funded position, list the title, the full time equivalent based on 2,080 hrs/year, the expected rate of pay, fringe rate (%), total annual salary and fringe, and the percent of each position being charged to the grant. Failure to provide the requested detail for each position may result in a delayed grant agreement. Please refer back to page 29-30 for an example of how to show your salary/fringe expenses.

Justification: REQUESTEDDOLLARS

Total Salary and Fringe $

2. Contractual Services: List the services applicant expects to contract out, the contractor’s or consultant’s name, whether the contractor is non-profit or for-profit, the length of time the services will be provided and the total amount expected to be paid. Supplies and travel of contractor should be included, if applicable. Itemize equipment rented or leased for the project.

Justification: REQUESTEDDOLLARS

Total Contractual Services $

3. Travel: Explain applicants expected instate travel costs, including mileage, hotel and meals. At a minimum, your organization must include the cost for at least one staff member to attend two MDH-sponsored statewide or regional meetings. If program staff will travel, itemize the costs, frequency and the nature of the travel.

Justification: REQUESTEDDOLLARS

Total Travel $

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4. Supplies and Expenses: Explain the expected costs for items and services the applicant will purchase to run the program. Include telephone expenses that are part of this proposal; cell phones and new telephone equipment to be purchased, if applicable. Estimate postage if part of the project. List printing and copying costs necessary for the project (other than occasional copying on an office copy machine). List office and program supplies and expendable equipment such as training materials, curriculum and software. Generally supplies include items that are consumed during the course of the project, equipment under $5,000.

Justification: REQUESTEDDOLLARS

Total Supplies and Expenses $

5. Other Expenses: Briefly describe any expenses that do not fit in any other category. Some examples include, but are not limited to: staff training, and incentives.

Justification: REQUESTEDDOLLARS

Total Other Expenses $

6. SUBTOTAL (Enter sum of lines 1 through 5): $

7. Indirect Costs: Enter your proposed indirect cost rate below. In the box to the right, enter the amount of indirect costs being requested. Indirect costs can be up to your federally approved indirect rate, or up to a maximum of 10%, multiplied by the direct expenses in the budget (line 6 of this form).

Indirect cost rate: _____%REQUESTEDDOLLARS

Total Indirect $

8. TOTAL (sum of line 6 + line 7) $

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Budget Summary InstructionsThis form should be used to show the total requested budget for the applicant’s proposed grant-funded activities for each time period of the program. The budget should include funding necessary in each category for each year of the grant. The total in each category should reflect the total of that category from the corresponding Budget Justification Form.

Please enter zero (0) in the Total Proposed Amount column if you do not propose to expend grant funds in a line item.

Enter the following items on the top portion of the Budget Summary Form: Name of MDH Grant Program for which the application is being submitted. Legal name of applicant agency applying for grant funds. Name of the contact person for questions regarding the budget being submitted. Telephone number for the contact person for the budget. Fax number of the contact person for the budget. E-mail address of the contact person for the budget.

1. Salary and Fringe : The total amount of grant funds that will be used during each time period on page 12 to cover salary/fringe benefits (add the figures from the “Total Salary and Fringe” box in all of the Budget Justification Forms).

2. Contractual Services : The total amount of grant funds the applicant plans to spend on contractual services (add the figures from the “Total Contractual Services” box in all of the Budget Justification Forms).

3. Travel : The total amount of grant funds that the applicant plans to spend on travel (add the figures from the “Total Travel” box in all of the Budget Justification Forms).

4. Supplies and Expenses : The total amount of grant funds that the applicant plans to spend on supplies and expenses (add the figures from the “Total Supplies and Expenses” box in all of the Budget Justification Forms).

5. Other : The total amount of grant funds that the applicant plans to spend on items that are not listed above (add the figures from the “Other Total” box in all of the Budget Justification Forms).

6. Subtotal : The sum of lines 1 through 5. This figure should match the sum of the subtotals on applicant’s Budget Justification Forms.

7. Indirect Costs : The total amount of grant funds that the applicant plans to spend for indirect costs. Indirect costs can be up to an applicant’s federally approved indirect rate, or up to a maximum of 10%, multiplied by the direct expenses in the budget (line 6 of this form). This figure should match the sum of the indirect costs on your Budget Justification Forms.

8. Total : The total in adding lines 6 and 7.

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Form F: Budget Summary FormComplete one form for each time period listed on page 22.

Name of MDH Grant Program:

Name of Applicant Agency:

Name of Contact Person for Budget:

Budget Period: _____________to ______________

Phone: Fax:

E-mail:

Line Item Total Proposed Amount1) Salary and Fringe

2) Contractual Services

3) Travel

4) Supplies and Expenses

5) Other

6) Subtotal (sum of lines 1 through 5)

7) Indirect Costs (your federally approved rate, or maximum of 10%, multiplied by line 6)

8) TOTAL (sum of line 6 + line 7)

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Indirect Cost Questionnaire InstructionsBackgroundApplicants applying for a grant from the Minnesota Department of Health (MDH) may request an indirect rate to cover costs that cannot be directly attributed to a specific grant program or budget line item. This allowance for indirect costs are a portion of any grant awarded, not in addition to the grant award.

It is important to know the difference between indirect costs and administrative costs before completing the Indirect Cost Questionnaire Form. Please refer to pages 31-32 for more detailed information on indirect costs.

InstructionsA. Fill in the applicant’s legal name.B. Check the appropriate checkbox.

1. If the applicant is not going to request any indirect costs, the applicant should check the first box and return the form as part of their application.

2. If the applicant has a federally approved indirect rate, the applicant should check the second box, follow the instructions listed, and return the form as part of their application.

3. If the applicant does not have a federal approved indirect rate, AND is planning to claim indirect costs, the applicant should check the third box, fill in the rate being requested, list the expenses being included in the indirect cost pool, and return the form as part of their application. The maximum indirect rate an applicant can request from MDH is 10%.

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Form G: Indirect Cost QuestionnaireApplicant’s Legal Name: _________________________________________

Program: 2017-2019 MIECHV Grant

Please check one of the three options below:

1. Not applicable

No charges to the grant program listed above are for indirect costs.

2. Federally Approved Indirect Cost Rate Agreement

A federally negotiated fixed rate is to be charged against all grant programs. A copy of the federally approved Indirect Cost Rate Agreement covering the current federal fiscal year is attached.

3. No federally approved indirect cost rate – requesting up to 10% maximum

Up to 10% of the direct expenses in the budget for the grant program listed above can be used for indirect costs per CFR Part 200 - Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards.

The applicant agency is requesting a rate of      % for the grant program listed above.

Per MDH Policy, the applicant must inform MDH of the types of costs included in the applicant’s indirect costs. Please list below.

     

     

     

     

     

     

     

     

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AppendicesAppendix A Evidence-Based Home Visiting Model Description

Appendix B Criteria for Scoring MIECHV Grant Applications

Appendix C MIECHV Work Plan Example (2017-2019)

Appendix D Expansion Information Form

Appendix E Average MIECHV Target Caseload Servced by Current Grantees during Calendar Year 2015

Appendix F High Risk Communities Identired in the Statewide Needs Assessment

Appendix G Link to MDH Grant Agreement Sample (This is sample language only. Actual language may vary for any applicant awarded a grant.)

Appendix H Unallowable Uses of MDH Grant Funds

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Appendix A: Evidence-Based Home Visiting Model DescriptionsFamily Spirit1 HFA2 NFP3

Theory A child’s development is optimally achieved through parents’ knowledge gained across the domains of physical, cognitive, social-emotional, language learning and self-help.

Rooted in the belief that early, nurturing relationships are the foundation for life-long, healthy development.

Shaped by human attachment, human ecology and self-efficacy theories.

Target population

Young, Native parents from pregnancy to 3 years post-partum

Designed for parents facing challenges (i.e. low income and/or history of abuse).

First-time, low-income mothers and their children.

Expected outcomes

1) Increase parenting knowledge and skills; 2) address maternal psychosocial risks that could interfere with positive child-rearing (i.e. substance use and/or depression); 3) promote optimal physical, cognitive, social- emotional development for children from 0 to 3 years; 4) prepare children for early school success; 5) ensure children get recommended well-child visits and health care; 6) link

1) Reduce child maltreatment; 2) increase utilization of prenatal care; 3) improve parent-child interactions and school readiness; 4) ensure healthy child development; 5) promote positive parenting; 6) promote family self-sufficiency and decrease dependency on welfare and other social services; 7) increase access to primary care medical services; and 8) increase immunization rates.

1) Improve prenatal health and outcomes; 2) improve child health and development; and 3) improve families’ economic self-sufficiency and/or maternal life course development.

1 Adopted from model descriptions and criteria included on the John Hopkins Bloomberg School of Public Health website: http://www.jhsph.edu/research/centers-and-institutes/center-for-american-indian-health/Research_and_Programs/Current%20Projects/Family_Services/Family_Spirit.html 2 Adopted from model descriptions and criteria included on the federal MIECHV website: http://mchb.hrsa.gov/programs/homevisiting/models.html 3 Ibid.

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Family Spirit HFA NFP

families to community services to address specific needs; and 7) promote parents’ and children’s life skills and behavioral outcomes across the lifespan.

Program components

Consists of 63 lessons delivered by Native American paraprofessionals to young Native parents from pregnancy up to the child’s 3rd birthday.

1) Screenings and assessments to determine families most likely to benefit from services; and 2) home visiting services.

Includes one-on-one home visits between a registered nurse educated in the NFP model and the client.

Intensity and length

Enrollment: recommended start at 28 weeks of pregnancy. Services: until child is 3 years. Visits: Lessons can be administered sequentially or independently, depending on the program structure and participants’ needs.

Enrollment: prenatally or at birth. Services: until child is 3 - 5 years. Visits: weekly for the first 6 months, followed by a decreased frequency depending on participants’ needs and progress toward goals.

Enrollment: up to 28 weeks of pregnancy. Services: until child is 2 years. Visits: Prenatal visits occur once a week for the first 4 weeks, then every other week until the baby is born. Postpartum visits occur weekly for the first 6 weeks and then every other week until the baby is 21 months. From 21-24 months visits are monthly.

Anticipated Number of Home Visits Per Year Per Model Fidelity

Visits are weekly for the first 6 weeks of prenatal enrollment, then every other week until the birth of the child.

Infancy visits are weekly for 6 weeks,

Pregnancy period – visits weekly or every other week until baby is born.

After baby is born – visits are offered weekly until baby is 6 months and parents are

Pregnancy period– visits once a week for first 4 weeks after enrollment; then every other week until the baby is born.

Infancy period- from birth of the child to 12

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Family Spirit HFA NFP

then every other week until seven months. Visits then decrease to monthly until the child turns two when visits are every other month. Visit schedules are flexible and can be tailored to each client as staff time allows.

making progress toward program goals.Visits decrease to every other week and as parents meet criteria, move to monthly. Some families facing greater challenges may continue weekly visits for a longer period of time until they show progress in meeting the criteria.

months of age; visits once a week for the first 6 weeks; then every other week through 12 months of age (27 visits maximum)

Toddler phase- Visits every other week from 13 – 20 months of age; then once a month from 21 – 24 months of age (22 visits max)

Costs Associated with Model Participation

Tailored Training Development and Implementation Affiliation Fee (includes technical and implementation assistance and support for sustainability):

$9,000 the first year per affiliate site.

$3,000 annually thereafter

Initial Site Training: $3,000 per

trainee $4,000 per

supervisor (at least one supervisor required for every 10 home visiting staff).

$1,800 for new trainees

HFA requires affiliation as the first step towards accreditation followed by accreditation which happens between years 2 & 3. Affiliation fee is payed when an affiliation application is submitted: $500Annual affiliation fees are payed each year until accreditation is achieved:

2016 Affiliates: $4500 each year

2017 Affiliates: $5000 each year

2018 Affiliates: $5000 each year

(HFA has offered a reduced affiliation rate for programs in MN that affiliate in 2016: $2,025 for yr. one, $3500 annually in subsequent years.)

The NFP program costs approximately $4,800 per family per year to fund and can range from $3,500 to $6,500 per family per year. Staff salaries are the primary driver that affects variability of cost.NFP Start-up Fee $27,461 includes;

initial support to help agency staff prepare to implement the program and successfully move through the initial phase of start-up,

education about implementation and access to the NFP data collection and reporting

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Family Spirit HFA NFP

at an affiliated site

$1,300 for refresher training for staff

Sites may choose to send staff to Albuquerque for training, additional travel costs for trainers may be incurred if sites wish to have on-site training.

Once a site achieve accreditation: annual fees to maintain accreditation are based on program size:Very small (up to 2.0 FTE) - $,1750Average (2.1 – 15 FTE) -$3,500Accreditation application fee=$250. Fee for the peer reviewer site visit is $2,700 for 2 reviewers for 3 days.If training for Integrated Strategies Core for Home Visitors or Parent Survey Core is required outside of what is available through MDH, costs per individual are $650 for each 4 day training, and an additional $215 for the supervisor to attend a required 5th day. Manual is covered in the cost of training.

system (ETO) incremental

program support and nurse consultation provided during the first two years of implementation

Nurse HV Initial Education - $4400Nurse Education Materials $559.Supervisor Initial Education - $5194.

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Appendix B: Criteria for Scoring MIECHV Grant ApplicationsProcedures for assessing the technical merit of applications have been instituted to provide for an objective review of applications and to assist the applicant in understanding the standards against which each application will be judged. Critical indicators have been developed for each review criterion to assist the applicant in presenting pertinent information related to that criterion and to provide the reviewer with a standard for evaluation. Review criteria are outlined below with specific detail and scoring points.

These criteria are the basis upon which the reviewers will evaluate the application. The entire proposal will be considered during objective review. Review criteria are used to review and rank applications.

Applicant Information (32 points)1. Does the applicant describe their agency’s history related to home visiting and if

applicable their experience implementing an evidence-based home visiting model?2. Does the applicant describe the local resources that are available to support or enhance

the efforts of the proposed application activities? Resources may include community achievements; strengths; experience;commitment; staff; interagency experience or cooperation on infrastructure tasks such as coordinated intake, screening and referral of familes.

3. Does the applicant describe support they have received related to the application including any governing board, advisory group or agency support?

4. Does the applicant describe in some detail their capacity to bill for home visiting services for Medicaid recipients of home visiting?

Linkages and Collaboration (45 points)1. Does the applicant describe their collaboration with community partners related to

planning for or implementation of the evidence-based model(s)? If applicable (a multi-site collaboration), does the applicant discuss any regional collaborations?

2. Does the applicant describe other home visiting programs in their community (including Early Head Start) and how the applicant will assure non-duplication of home visiting services and coordination of home visiting services in the community such as coordinated intakes, regular meetings to discuss referrals, community agreement on clients to be served by home visiting programs, eligibility criteria for each community home visiting program.

3. Does the applicant clearly describe the members of the community advisory board? Does the community advisory board broadly represent the community, i.e. funders, community partners, families who have received home visiting services? Is the role of the community advisory board clearly defined including frequency of meetings?

Subcontracts (10 points)If the applicant proposes to contract out services, does the applicant:

1. Describe the service to be contracted for;2. Provide anticipated contractor information including name and selection process to be

used;

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3. Length of time the services will be provided; and,4. Total amount to be paid to the contractor?

Statement of Need: Proposed High Need Area and Families to be Served (36 points)1. Has the applicant identified the community need that the applicant hopes to address

with the application and proposed activities?2. Does the applicant include in their description of need:

a. A target population;b. Any needs assessment that was completed by the applicant separately or in

collaboration with other community partners;c. Identification of, rationale for proposing and feasibility to serve a county contiguous

to the high risk community and not identified as high risk for the application;d. Waiting list for home visiting services especially for those sites considering

expansion or other information demonstrating need for expanded services?3. Does the applicant include any results from a planning process or use of a tool such as

the Zero to Three Home Visiting Community Planning Tool to determine need and capacity for the proposed implementation or expansion of the proposed evidence-based home visiting model(s)?

Continuous Quality Improvement (27 points)1. Does the applicant describe and appear to have an understanding of the quality

assurance/quality improvement requirements of the evidence-based model(s) proposed to be implemented?

2. Does the applicant have an understanding of the barriers and challenges that may be faced in conducting quality improvement activities? Does the applicant propose resolutions to those challenges or overcoming barriers?

3. Does the applicant describe a plan and capacity to utilize data for quality improvement activities?

Evaluation/Data Collection (30 points)1. Does the applicant clearly describe the capacity to collect and report demographic,

service utilization, benchmark, and outcome data?2. Is there a clear description of the applicant’s current activities and methods for data

collection and analysis including frequency of those activities?3. Does the applicant clearly describe how they assure data quality and the applicant’s

data management and analysis experience? Do they provide examples of data analysis?4. Does the applicant describe an informed consent process being in place? Does the

applicant describe policies or procedures related to maintaining data safety and security?

5. Is the applicant able to describe barriers or challenges to collecting and reporting data? Does the applicant suggest strategies they will use to overcome barriers or challenges?

Model(s) Selection and Target Caseload (56 points)

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1. Does the applicant clearly describe how the selected evidence-based model(s) will address the high risk community and the high risk target population selected by the applicant?

2. Does the applicant identify the needs or gaps in the community’s home visiting continuum and how the selected model(s) will address those needs or gaps?

3. Does the applicant describe a plan ensuring non-duplication of home visiting services in the community? Does the plan support the delivery and non-duplication of home visiting services in the community?

4. Is there a clear description of the applicant’s capacity and readiness to implement the proposed model(s) including the capacity to hire, train and retain staff.

5. Has the applicant discussed the proposed activities with the model developer? Has the applicant submitted any documents related to the proposed activities to the model developer? Does the applicant describe any feedback received from the model developer regarding proposed activities? Has the applicant addressed any feedback received from the model developer?

6. Does the applicant describe the challenges and risks in implementing the proposed model(s)? Does the applicant describe challenges to maintaining fidelity to the model(s)? Are there proposed activities to address those barriers or risks?

7. Does the applicant include a target caseload? Does the applicant clearly describe how the target caseload was selected? If previously funded by MIECHV, does the applicant describe past experience in achieving and maintaining 85% of the target caseload? If the applicant is requesting a target caseload greater than their 2015 average, does the applicant include information about changes the applicant is making to their data collection and reporting submitted to MDH to assure accurate data reporting in the future and explain their rationale for the higher than 2015 target caseload?

8. Does the applicant describe challenges or barriers to achieving 85% of target caseload and activities to be implemented to address those challenges or barriers?

Implementation Plan (72 points)1. Is there a clear plan for recruiting, hiring, training and retaining appropriate staff for the

positions associated with proposed activities?2. Does the applicant clearly identify that every home visitor works at least .5 FTE

implementing the model? If the home visitor is less than .5 FTE on the proposed application funding source is it clear that the home visitor is funded by other funding streams that would allow for the home visitor to be at least .5 FTE implementing the model?

3. Does the applicant describe how high quality reflective practice including infant mental health consultation for all home visitors and supervisors will be provided? Is there a description of challenges that may be faced in providing reflective practice and infant mental health consultation? Are there suggested activities that will help address those challenges?

4. Does the applicant describe a clear plan for identifying and recruiting high risk families? Does the applicant describe how they will minimize attrition of families? Does the applicant appear to have the capacity and linkages needed to recruit families?

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5. Is the timeline to achieve and maintain the target caseload feasible?6. Does the applicant describe the capacity and a plan to maintain model(s) fidelity? Does

the applicant demonstrate an understanding of possible barriers to implementing a model with fidelity? Are there strategies described that would address challenges or barriers to implementing a model with fidelity including resources that may be needed?

7. Does the applicant demonstrate a commitment to development of a policy related to enrollment, disengagement and re-enrollment including non-duplication of services?

8. Is there a referral network described by the applicant? Does the referral network include entities that may refer to the applicant? Are there clear relationships with those entities? Does the applicant provide information on entities they may refer clients to and demonstrate an understanding of the need of clients that may be served by the applicant?

Work Plan: Goals, Objectives, and Strategies (63 points)1. Do the activities outlined in the work plan demonstrate the applicant’s capacity to

report data quarterly?2. Will the proposed activities support the applicant in submitting quarterly reports

regarding activities completed?3. Will the proposed activities support the applicant in being able to identify members and

the purpose of the community advisory board to provide guidance related to program implementation?

4. Will the proposed activities result in the applicant being able to develop a policy assuring coordination of home visiting programs in the community and non-duplication of home visiting services?

5. Will the proposed activities support the applicant in achieving and maintaining at least 85% of the target caseload during the grant period?

6. Will the proposed activities result in the applicant being able to achieve and maintain model approval, affiliation or accreditation and retain model fidelity throughout the grant period?

7. Will the proposed activities achieve and implement a plan between the applicant and community partners to integrate home visiting into the early childhood system in the community?

Need for Technical Assistance (9 points)Does the applicant clearly describe anticipated need for technical assistance or training and resources that may be available?

Budget (48 points)1. Are the budget forms complete?2. Do the amounts in the Budget Summary and the Budget Justification match?3. Is the information contained in the budget and work plan consistent? Will the budget

support the activities identified in the work plan?4. Are the projected costs reasonable, cost-effective and sufficient to accomplish the

proposed activities?

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Appendix C: MIECHV Work Plan Example – 2017-2019 Grant RFPCommunity Health Board or Tribal Nation:

Counties Included in Application:

Contact Person for Work Plan including name, email, and phone no.:

Date Submitted:

Target Caseload for Model to be Implemented:

_____ Healthy Families America _______ Nurse-Family Partnership _______ Family Spirit

Objectives ActivitiesBy January 1, 2017 develop a referral network for incoming referrals to the program and resources that the program will refer families to based on need.

Identify priority partners that are potential referral sources of the target population.

Identify resources in the community that can provide additional support services to families.

Develop plans for outreach activities to priority partners and community resources.

Formal MOU agreements executed with priority partners.

By February 1, 2017 identify members of a CQI team and begin participation in the MIECHV CQI Learning Collaborative.

Identify members of a CQI team. Participate in MIECHV CQI Learning Collaborative

meetings. Identify CQI projects related to implementation

of their chosen model or connecting with the early childhood system in the community.

Implement, track, and report on CQI projects.By March 1, 2017 identify members and purpose of the community advisory board and implement utilization of the community advisory board to provide guidance for program implementation.

Adhering to model guidelines, define the role and purpose of the community advisory board.

Identify and invite partners to participate on the community advisory board.

Schedule a meeting for the community advisory board and regularly scheduled meetings.

By March 1, 2017 a plan will be developed identifying potential funding sources and next steps to provide program sustainability.

Seek/maximize Medicaid reimbursement for services provided to eligible families.

Seek technical assistance from MDH or DHS for reimbursement challenges.

Assign staff to review and address any errors or missed reimbursement opportunities.

Pursue other funding/grant opportunities to support home visiting programs to at-risk families.

Engage key stakeholders in support of program.By March 1, 2017 a plan will be developed and implemented for how reflective practice support will be provided for program

Conduct monthly team reflective supervision with licensed mental health provider or skilled infant mental health consultant. (Level III or IV).

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Objectives Activitiessupervisors and home visitors throughout the grant period.

Supervisor will receive monthly 1:1 reflective supervision with an individual skilled in RP consultation and provide reflective supervision to the home visitors per the model expectations.

Supervisor provides joint home visits with each home visitor per model expectation.

By April 15, 2017 and quarterly thereafter submit quarterly reports to MDH related to activities in this work plan.

Review work plan activities of previous quarter at staff meeting.

Identify successes and challenges in implementing activities for the quarter.

Identify need for technical assistance related to challenges in achieving activities and objectives.

Submit quarterly report. By April 15, 2017 and monthly thereafter submit data as outlined in the current version of the Family Home Visiting Reporting Guidance document for submission to MDH via FHVRES or other designated data reporting system.

Implement written informed consent process to allow reporting of individual-level data to MDH for MIECHV evaluation purposes.

Collect data for performance measurement. Monitor the quality of data collected for

performance measurement. Submit data to FHVRES or other data collection

systems designated by MDH.By May 1, 2017 develop policies as directed by MDH. Policies will include but not be limited to a policy assuring coordination of home visiting programs in the community and non-duplication of home visiting services.

Identify all home visiting programs available to target population within the community.

Convene a meeting with other home visiting service providers for the purpose of identifying role and scope of programs to reduce duplication.

Develop a written policy that assures ongoing coordination and collaboration with other service providers.

By January 1, 2017 for previously funded MIECHV sites and May 1, 2017 for new MIECHV sites achieve and maintain model approval, affiliation or accreditation and retain model fidelity through the grant period.

Contact model representative to discuss requirements for model affiliation, replication, or implementation process.

Participate in regular, periodic consultation with model developers/model consultants.

Review fidelity or quality reports on a quarterly basis, for opportunities for growth.

By June 1, 2017, a plan with community partners will be developed that integrates home visiting into the early childhood system in the community and implement the plan throughout the remainder of the grant period.

Develop/Implement plans for Help Me Grow referrals.

Develop/implement plans for how referrals to Early Childhood Screening will be made.

Collaboration and coordination of referral process within the early childhood system partners, including Early Head Start to assure a continuum of services.

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Objectives Activities Develop a plan to establish bi-directional

communication between the program and medical home/behavioral health home.

By May 1, 2017 for previously funded MIECHV sites and December 31, 2017 for new MIECHV sites achieve a full case load of families to be served and maintain the caseload at 85% during the grant period.

Report quarterly to MDH percent of target caseload being served on Quarterly Progress Report.

If below 85% of target, develop plan and provide progress reports to MDH.

Supervisor to monitor caseloads on a monthly basis.

Conduct CQI activities to improve/maintain client engagement and retention.

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Appendix D: Expansion Information FormThe Nurse-Family Partnership Expansion Information Form is available by contacting Amy Goodhue, Nurse-Family Partnership Nurse Consultant at amy.goodhue@nursefamilypartnership.org.

If you are a current Nurse-Family Partnership site, you may also access the form by going to the Nurse-Family Partnership website and logging on to the NFP Community tab.

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Appendix E: Average MIECHV target caseload served by current grantees during Calendar Year 2015The table below gives the quarterly caseload served by each current MIECHV grantee during Calendar Year 2015, based on data submitted to MDH. Figures include families served by both MIECHV 1 and MIECHV 2 funds.

Table E1 Average MIECHV Target Caseload Served by Current Grantees During Calenar Year 2015

Grantee Q1 2015

Q2 2015

Q3 2015

Q4 2015

Average 2015

Anoka 65 62 69 69 66Bloomington, City of 24 26 26 35 28Carlton-Cook-Lake-St. Louis 52 49 50 43 49Cass 7 6 6 6 6Dakota 52 62 71 70 64Hennepin 75 80 77 78 78Isanti-Mille Lacs 25 24 24 23 24Kanabec-Pine 73 81 80 81 79Meeker-Mcleod-Sibley 25 22 22 22 23Minneapolis, City of 151 163 188 130 158Morrison-Todd-Wadena 10 9 10 11 10Mower 29 26 26 25 27North Country (Beltrami-Clearwater-Hubbard-Lake of the Woods) 48 52 53 56 52

Partnership4Health (Becker-Clay-Otter Tail-Wilkin) 51 45 36 40 43

Polk-Norman-Mahnomen 14 13 12 20 15Quin (Marshall-Pennington-Red Lake) 30 30 29 28 29St. Paul-Ramsey 316 317 306 290 307Stearns 89 92 73 70 81Washington 45 47 49 48 47

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Appendix F: High Risk Communities Identified in the Statewide Needs Assessment

County CountyAitkin Mille Lacs Anoka MowerBecker NoblesBeltrami NormanBig Stone OlmstedCarlton PenningtonCass PineClearwater PipestoneCook PolkCrow Wing PopeDakota RamseyFaribault Red LakeHennepin RedwoodHubbard ScottItasca StearnsKanabec St. LouisKandiyohi SwiftKoochiching ToddLake TraverseLake of the Woods WadenaMahnomen WashingtonMarshall WatonwanMartin Wright

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Appendix G: Minnesota Department of Health Grant Agreement Sample

Please review the MDH Grant Agreement Sample language on the Family Home Visiting website. This is sample language only, actual language may vary.

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Appendix H: Unallowable Uses of MDH Grant FundsUnallowable costs are expenditures in which grant funds cannot be used. MDH does have the right to disallow expenditures if grantees do not obtain prior approval. The MDH Grant Manager will be reviewing invoices and reserves the right to question and/or take action for inappropriate uses of funds. The following list of unallowable uses of grant funds include, but are not limited to, the following:

Alcohol or any illegal substance Any cost not directly related to the grant and it’s approved work plan and budget Bad debts Capital improvements Cash assistance paid directly to individuals to meet their personal or family needs Contingencies Contributions or donations Costs incurred prior to or after the grant award (unless otherwise indicated) Direct patient medical services or care Equipment with an acquisition cost of $5,000 or more per unit Fines and penalties Gifts for staff Goods or services for personal use Grant writing Interest Lobbying at the federal or state level Losses on agreements or contracts Memberships to clubs, camps, fitness centers and similar groups Mischarging of costs Personal electronic devices, such as Smart phones, iPhones, iPads, etc. Political campaigns on behalf of, or in opposition to, any candidate for public office Raffles Research Scholarships (e.g. camp fees and scholarships for individuals to participate in events) Staff meals (except during approved travel) Supplanting of funds from other sources Transportation (except during approved travel) Treatment of a disease or disability

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