MAINE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING EXPANSION PROJECT ABSTRACT

Transcription

1 MAINE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING EXPANSION PROJECT ABSTRACT Applicant Name: Sheryl Peavey, Director, Early Childhood Initiative, Maine DHHS Address: Office of Child & Family Services, SHS #11, 2 Anthony Avenue, Augusta, ME Contact Phone Numbers: Phone: (207) ; Fax (207) Address: [email protected] Web Address: The Maine Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Expansion Project represents the culmination of years of state and local work towards an accountable, evidence based, data-driven and family-centered home visiting continuum of services. This project will increase direct service capacity, incent community collaboration, amplify program evaluation, and implement purposeful sustainability strategies in a unique, comprehensive and powerful way to benefit Maine s vulnerable families in at-risk communities. Maine's 2010 Home Visiting Needs Assessment, including statewide stakeholder meetings and interviews, pointed to the need for increased coordination not only among different home visiting and home-based programs, but also among with the broader early childhood services system. In particular, there are gaps around serving families with substance abuse and mental health needs, and the data show that needs are increasing: rates of drug-affected babies in Maine have nearly tripled in recent years, rates for opiate treatment admissions have consistently topped other states, and our children experience the highest poverty rates in New England. Serving vulnerable families in our rural state and tribal nations is further complicated by challenges with transportation, travel time, and insufficient workforce skilled in engaging isolated families. The needs assessment also examined service capacity, and Maine has in place a core program upon which to responsibly expand home visiting services and more effectively coordinate state and local resources. The Maine Families Home Visiting program is a network of state-funded programs in every county delivering the evidence-based Parents as Teachers model since Its performance based contracts are guided by rigorous standards of practice and continuous quality improvement. With federal funding, Maine is aligning its existing evaluation and webbased data collection with the federal MIECHV benchmarks and providing the Touchpoints and other specialized multi-disciplinary training so that community partners can more consistently and respectfully serve the families facing substance abuse, co-occurring disorders, and domestic violence issues. The expanded Maine Families program will be integrated into this already existing system and will be evaluated through a partnership with the University of Southern Maine and its epidemiology team. Most importantly, to address sustainability, this project leverages the financial, intellectual and social resources already at play in Maine: a Legislature that diversified home visiting funding in recognition of its centrality within the early childhood system, national experts offering technical assistance for state Medicaid improvements, a history of accountability and finding cost efficiencies, and the successful social marketing strategies of the state s early childhood advisory council, the Maine Children s Growth Council. The thoughtful combination of direct service delivery, community collaboration, evaluation, and sustainability strategies on top of an already proven structure and network offer a compelling model for successful home visiting in all states. Maine MIECHV Expansion Project Abstract HRSA

2 State of Maine Maternal, Infant and Early Childhood Home Visiting (MIECHV) Expansion Project Proposal Narrative TABLE of CONTENTS Introduction...1 Needs Assessment...6 Methodology...9 Work Plan...19 Resolution of Challenges...33 Evaluation and Technical Support Capacity...34 Organizational Information...43 INTRODUCTION Project Purpose Maine s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Expansion will serve to strengthen, enhance, and expand the state s existing statewide home visiting program, Maine Families, as part of a comprehensive early childhood system. While Maine already has a solid statewide network of Maine Families sites implementing Parents as Teachers (PAT) and following rigorous standards of practice, the state needs additional resources in order to: 1. Reach greater numbers of eligible families (including: those with needs related to substance abuse, mental health, co-occurring disorders, and/or family violence, those in rural areas, and those living in tribal communities). 2. Better serve vulnerable families through enhancement of the PAT program that includes provision of more frequent visits to families who need them; additional training and clinical supervision for home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, co-occurring, and/or family violence issues; and strengthening of coordination and collaboration among local service providers to better serve families in need. For the purposes of this application, these collective efforts are termed the Maine Families Linking Initiative. 3. Increase capacity of all Maine Families sites to participate in data collection and reporting according to federal Benchmark requirements. 4. Strengthen state-level systems collaboration for a coordinated continuum of early childhood services, with home visiting as a sustainable and integral component of that system. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

3 Maine s history of home visiting in a comprehensive early childhood system Maine s proposed program expansion will build on an already existing network of statewide home visiting services. Home visiting began in Maine at the grassroots level in the late 1980 s, resulting in a diverse array of home visiting programs throughout the state. In 1997, the state used General Funds to initiate a pilot home visiting program in six counties. In 2000, the Maine Home Visiting Program was launched so that eligible families in every county could have universal access to home visiting. Initially, communities could choose from one of three models: Healthy Families America, Parents as Teachers, and a homegrown model, Parents are Teachers, Too. In 2007, under a new state administrator, home visiting sites examined the literature, came to consensus on best practices, and, with the state, established shared Standards of Practice. The Touchpoints approach was also adopted, providing a focus on reflective practice and reflective supervision; with the blessing of the Brazelton Touchpoints Center, Maine established a state Touchpoints Coordinator and Home Visiting Training Team. In 2008, Maine selected Parents as Teachers (PAT) as its statewide curriculum. The Maine PAT training team was developed and all staff became Certified Parent Educators. At that time, the state chose to use a single statewide model in order to increase commonality and consistency among program sites and provide a singular basis for performance and quality assurance. Use of a consistent curriculum and parent materials was especially important as families frequently moved from one county to another. PAT was selected because it was a national model that most program sites were already partially invested in. Maine providers preferred PAT because it was regarded as a more strength-based and respectful approach than other models and was a fit with Maine communities and programs' philosophy. In 2010, the state re-branded the network of programs as Maine Families. Today, Maine Families continues to be the core of statewide home visiting services, with trained staff in every county reaching 2,500 families per year. Maine Families sites follow rigorous Standards of Practice that include fidelity to PAT and the use of the Touchpoints approach in reflective practice and reflective supervision. Quality assurance and technical assistance are provided by an in-state team led by the Maine Families Statewide Coordinator. All Maine Families programs share a single web-based data collection system that allows for statewide evaluation and continuous quality improvement. These strategies help to ensure model fidelity, consistency, and coordination of home visiting statewide. The proposed enhanced program will be integrated into this already existing system and will build on our highly trained, highly skilled Maine Families workforce. Maine Families sites work in close collaboration with other home-based programs in the state. The Maine CDC Public Health Nursing program (and its grantees, Community Health Nursing) serves approximately 4,600 families per year statewide. On a local level, Maine Families and home-based nursing programs work closely together to ensure that family needs are met. Because the nurses work with families only for the duration of specific health needs (typically under 6 months), they frequently refer families to the Maine Families program. Maine also has Early Head Start home visiting programs in 10 of 16 counties, serving just under 500 families per year. The Maine Families program operates out of the Department of Health and Human Services Office of Child and Family Services (OCFS), through a collaborative agreement with Maine Center for Disease Control s (CDC) Division of Maternal and Child Health. This administrative structure further helps to promote collaboration and coordination of services. The Maine Families program is administered by Sheryl Peavey, Director of the Early Childhood Initiative within the Office of Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

4 Child and Family Services. Ms. Peavey has guided the development of the Early Childhood Systems Plan since the inception of the Maternal and Child Health Bureau Early Childhood Comprehensive Systems (ECCS) grant in Maine s broader early childhood systems efforts through the ECCS grant have included quality home visiting services as a core component of the state plan since its inception. As the Public Health-Child Welfare Liaison, Ms. Peavey leads the home visiting work and other child maltreatment prevention efforts as a representative of both the Maine OCFS and the Maine CDC. Ms. Peavey is also responsible for staffing and coordination of the Maine Children s Growth Council, which is the state s Early Childhood Advisory Council. Maine s home visiting providers, together with OCFS, the Maine CDC, and the Maine Children s Trust Fund, have been working collaboratively to take steps toward developing a more coordinated state system. Stakeholder meetings have included Maine Families home visiting program managers, Public Health and Community Health Nursing, Early Head Start and Head Start Directors, child protective caseworkers, child welfare leadership, state agency substance abuse representatives and community providers, advocates and others. Open communication has been a hallmark of the early childhood systems work and is key to sustainability, so all relevant home visiting systems documents are available online at the Maine Children s Growth Council website ( As history demonstrates, Maine is committed to implementation of home visiting as part of a comprehensive early childhood system one that emphasizes evidence-based practice, quality assurance, and optimal coordination of services. Maine proposes to use the MIECHV Expansion grant to assist the state in furthering its systems-level work as well as enhancing and expanding direct services provided by Maine Families. State Commitment to Home Visiting As described above, there have been steps taken by the state for more than a decade to have a cohesive and accountable network of home visiting programs in Maine. Until recently, these were supported financially using special revenue from the tobacco settlement, known in Maine as the Fund for Healthy Maine (FHM). Home visiting survived despite annual budget threats from one state agency manager who did not value prevention as a means for social and economic savings for Maine. In 2011, during the transition to a new administration, this manager set in motion a proposal to eliminate all funding for home visiting in the Governor s budget, a move that was resoundingly defeated with bipartisan support in the Legislature and actually propelled the Maine Families program into the spotlight as a model for accountable and effective evidence based programming. The local, state, and even national advocacy for the Maine Families program during the legislative session was possible because of years of early childhood systems work in this state: the maturing social marketing campaign of the Maine Children s Growth Council that heightened public awareness of the architecture of the developing brain; the powerful print/media presence of Maine s chapters of three national, reputable organizations (Fight Crime: Invest in Kids, America s Edge, and Mission Ready); the program s solid evaluation data providing current and historical evidence of improved child outcomes with cost-efficiency; and national and local testimony that engaged legislators and the Executive Branch alike. As a result, Maine Families Home Visiting emerged as a core state investment in primary prevention. Rather than lose all of its funding, the entire $4.6 million was restored, but restored using diversified funding to represent the cross-systems influence of home visiting. Home visiting is now Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

5 supported by state general funds from the Child Care Development Fund (CCDF) match account acknowledging its part in the state CCDF plan, state general funds from foster care, and the Fund for Healthy Maine special revenue. This unprecedented restoration of funding is joined by other state actions demonstrating a solid commitment to home visiting: 1. Governor LePage signed LD 1504, a Resolve to Ensure a Strong Start for Maine's Infants and Toddlers by Extending the Reach of High-quality Home Visitation that aligns state and federal intentions for home visiting and addresses sustainability in state statute; 2. The DHHS Commissioner s Grants Review Committee has stipulated quarterly reports on the progress of implementing the state home visiting plan, demonstrating an interest and level of oversight for home visiting absent in the past; 3. The Maine Children s Growth Council Communications Committee will be focusing its public policy campaign on home visiting in the upcoming biennium, capitalizing on solid partnerships with Fight Crime; America s Edge, and Mission Ready as well as the media generated from the state s MCH New Motherhood Initiative demonstration grant; and 4. The former Director of OCFS has been replaced with new leadership with a track record of collaboration, accountability, and a strong desire to ensure that Maine s youngest children start their lives in healthy, safe, and nurturing communities. Please see our section on Commitment and Sustainability (pp , 32, 49) for more detail about Maine s plans for ongoing high-quality home visiting services. The Problem, The Intervention, The Project Benefit The Problem: While Maine already has a solid statewide network of Maine Families sites implementing Parents as Teachers and following rigorous standards of practice, the state has identified the following needs or gaps: 1. Many eligible families are not being reached (including those with needs related to substance abuse, mental health, co-occurring disorders, and/or family violence, those in rural areas, and those living in tribal communities). 2. Many participants need enhanced services linking them to additional supports. This need is especially urgent for families who are facing challenges with substance abuse, mental health, co-occurring disorders, and/or family violence. 3. Maine Families sites statewide are not yet fully prepared to collect and report according to federal Benchmark requirements. 4. Maine needs increased state-level systems collaboration to build a coordinated continuum of early childhood services with home visiting as a sustainable and integral component. The proposed intervention: To expand and enhance implementation of Maine Families home visiting program by: 1. Increasing Maine Families staffing (trained home visitors) to reach greater numbers of eligible families (including: those with needs related to substance abuse, mental health, cooccurring, and/or family violence, those in rural areas, and those living in tribal communities) 2. Enhancing implementation of PAT model program by implementing a statewide Linking Initiative that includes the following elements: a) Increasing Maine Families staffing and travel budget to provide greater frequency of visits to families who need them, Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

6 b) Providing increased training and clinical supervision for Maine Families home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, co-occurring, and/or family violence issues, c) Offering assistance from consultant/facilitator, supporting local staff time, and supporting shared training opportunities to strengthen local linking efforts to build coordination and collaboration among service providers. 3. Working with the evaluator to develop and maintain statewide and local level data collection, reporting, and analysis according to federal benchmark requirements. 4. Working with the consultant/facilitator and supporting state staff time to build a coordinated continuum of early childhood services statewide while strengthening the long-term sustainability of Maine s home visiting system. The expected benefit: As a result 1. More eligible families will be reached with home visiting. 2. Vulnerable families will be better linked to needed services: a. More families will be able to receive frequency of visits that match their needs. b. Home visiting staff will be better prepared to engage and assist families with substance abuse, mental health, co-occurring, and/or family violence issues. c. Stronger coordination and collaboration among local service providers will ensure that more families receive needed services. 3. Statewide and local level data collection, reporting, and analysis will align with federal Benchmark requirements. 4. Maine will have a more coordinated continuum of early childhood services that includes long-term sustainability of Maine s home visiting system. Maine anticipates that the above results will contribute to measurable health and wellness outcomes for Maine Families participants, including progress in the MIECHV Benchmark categories of Improved Maternal and Newborn Health; Reduction of Child Injuries, Child Abuse, Neglect, or Maltreatment; Improved School Readiness and Achievement (including improvements in Positive Parenting Practices); and Reduction of Domestic Violence. Further, as a longstanding contributor to the State s Maternal and Child Health Block Grant application, the data from this program can help drive state policy and funding changes in a more informed way. Priority elements to be addressed Maine has selected Priority Element 7: To reach families in rural or frontier areas through home visiting programs because it encapsulates the public health and systems improvement priorities that are outlined in our State Plan. The public health challenges facing Maine are largely related to its rural nature. In our 2010 Needs Assessment, home visiting stakeholders in each of Maine s 16 counties reported challenges around engaging isolated, rural families. How this proposal builds on Maine s existing MIECHV program Using its Needs Assessment data, Maine identified two locations as its most at-risk counties as Tier 1 sites, and directed the first wave of MIECHV funding to bolster the direct service capacity and infrastructure for those regions. This proposal will take those changes in a responsible and thoughtful statewide expansion and assist Maine in attaining its goal of reaching more families in rural areas by providing resources to enhance services, increase staffing and travel resources, and increase local collaboration among early childhood providers so that more rural families can be reached, and isolated families can be better engaged. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

7 The Logic Model for Expansion (as related to the existing MIECHV program) Maine s current home visiting program consists of a statewide Maine Families network that is well-established in using the Parents as Teachers model. Our MIECHV Updated State Plan selected two communities, Penquis (Pistataquis/Penobscot Counties) and Washington County, as pilot sites for enhanced Maine Families programming that includes the Linking elements listed above. Maine s proposed MIECHV Expansion will use lessons learned from the pilot communities to implement these enhancements statewide involving state-level partners as well as every local Maine Families site and their local partners to create lasting, systems-level change. Our MIECHV Expansion logic model is provided in Attachment 1. NEEDS ASSESSMENT Selected Communities Maine has selected the entire state as its community to serve with expanded and enhanced implementation of the Maine Families home visiting program. Our 2010 Needs Assessment and 2011 Updated State Plan provided a tiered ranking of Maine s 16 counties based on both risk and readiness; this prioritization was conducted in case of insufficient resources to support enhanced programming statewide. In the event of funding levels that could adequately support statewide implementation, Maine s intent has always been to enhance programming in each of its 16 counties. With only 13,000 to 14,000 babies born across the state every year, and a history of successful statewide implementation of Parents as Teachers, Maine has a unique capacity to implement the proposed expansion on statewide level. In addition, all 16 counties have demonstrated need and readiness to implement the proposed program. Demographic overview o An extremely rural state, Maine has a population of 1.33 million people spread across more than 33,000 square miles roughly the size of all other five New England states put together. o According to 2010 Census data, Maine s population is 95.2% White, 1.2% Black/African American, 1% Asian, 1.3% Latino, 1.6% Multiracial..3% Other, and.6% Native American. o Higher racial diversity can be found in the southern part of the state. Maine s largest city, Portland, has a population of only 66,194, of whom 85% are White. o More than 8,500 Mainers identify as Native American, making up.6% of the state s population and living primarily in the northern part of the state. Maine is home to five American Indian tribal communities: Penobscot Nation, Mi kmaq, Houlton Band of Maliseet, Passamaquoddy at Indian Township, and Passamaquoddy at Sipiyak. Community Needs Maine's 2010 Home Visiting Needs Assessment process was followed by two statewide stakeholder meetings and a series of in-depth one-on-one interviews with stakeholders across the state including local and state-level representatives from Maine Families, Public Health Nursing, Community Health Nursing, and Early Head Start home visiting programs. These meetings clearly pointed to the need for increased coordination not only among different home visiting programs, but also between home visiting and the broader early childhood services structure. In particular, participants emphasized a need to address existing gaps around serving families with substance abuse and mental health needs. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

8 Another common theme was the need to better serve families in rural areas. In our 2010 Needs Assessment and follow-up process, home visiting stakeholders in each of Maine s 16 counties reported challenges surrounding transportation, travel time, and engaging isolated, rural families. Available data points to statewide need in the following priority risk areas: Children in Poverty: Maine has the highest poverty rates in New England. 46,350 Maine children (17.5% of children under age 18, and 21.4% of children under age 5) were living in poverty in Domestic Assault: Statewide, 5,311 domestic assaults were reported to police in 2008 an average rate of 4 reported domestic assaults per 1,000 people. 2 Substantiated Child Maltreatment and Neglect: 3,703 Maine children ages 0-17 were victims of substantiated child maltreatment in 2009, a rate of 13.4 per 1,000 children. 2,654 Maine children were victims of neglect, a rate of 9.6 per 1,000 children. 3 Children in DHHS care or custody: 1,650 Maine children (6% of children statewide) were in state care or custody in 2009 a rate of 6 per 1000 children. 4 High School Drop-out: Total high school graduation rate for Maine public schools was 82.82% for the school year. 5 Infant Mortality: Maine s infant mortality rate is 6.1 per 1,000 births. 6 Substance Abuse: o More than 1 in 5 Mainers (22.1%) ages 12 and older report binge alcohol use, and nearly 1 in 10 (8.3%) report using marijuana in the past month. 7 o Nearly 1 in 20 Mainers (4.2%) report non-medical use of prescription pain relievers an estimated 47,916 people statewide. 8 o Maine has consistently topped other states in opiate treatment admission rates over the last 20 years. 9 o Maine s Drug Affected Baby rates have nearly tripled in recent years, from 201 drug affected babies reported in 2006, to 572 drug affected babies in 2010 a rate of 4 per 100 babies. 10 o Statewide hospital data from 2008 shows that 215 newborns were discharged with drug withdrawal (Neonatal Abstinence Syndrome). 11 Mental Health: More than 1 in 10 Mainers (11.5%) ages suffer from frequent mental distress, with county rates ranging from 9% in York County to 18.9% in Piscataquis County Maine DHHS, Center for Disease Control and Prevention, Office of Data, Research, and Vital Statistics, accessed 3/ Department of Public Safety, Maine State Police, Uniform Crime Reporting Unit, as reported by USM, 8/ Maine Kids Count, 2010; Office of Child and Family Services, Maine Department of Health and Human Services. 4 Maine Kids Count, 2010; Office of Child and Family Services, Maine Department of Health and Human Services retrieved 6/13/11 6 U.S. Census Bureau, American Community Survey; Maine DHHS, Center for Disease Control and Prevention, Office of Data, Research, and Vital as reported by USM 8/ , 2007, 2008 National Survey on Drug Use and Health (NSDUH) 8 ibid 9 Treatment Episode Data Set (TEDS) , page 76. Retrieved on 6/16/2010 from 10 Mandy Milligan, Maine Automated Child Welfare Information System (MACWIS), Maine Office of Child and Family Services 3/15/ USM analysis of 2008 Maine hospital discharge dataset, 8/2010 Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

9 In almost all risk categories, areas with higher population have higher absolute numbers, while rural areas have higher rates. For example, child poverty rates range from 11.9% in Maine s most populated county of Cumberland (6,768 children in poverty) to 29% in Washington County (1,821 children in poverty). This phenomenon further underscores the need for implementation of Maine s enhanced home visiting program on a statewide level, rather than selecting one county over another. In addition, while risk data specific to the tribes is not available because the tribes are in the midst of their public health systems assessments, Maine is committed to exploring need and interest for increasing home visiting services available for the five tribal communities in Aroostook, Penobscot, and Washington Counties. Community Readiness As mentioned in the Introduction, Maine s proposed program expansion will build on an already existing network of statewide home visiting services, the Maine Families program. Maine Families providers are already established in every county, reaching approximately 2,500 families per year. Rigorous evidence-based standards are already in place. Since 2008, all Maine Families sites have been consistently implementing Parents as Teachers and using the Touchpoints approach of reflective practice and reflective supervision. Quality assurance and technical assistance are provided by an in-state team led by the Maine Families Statewide Coordinator. All Maine Families sites share a single web-based data collection system that allows for local and state-wide evaluation and continuous quality improvement. These strategies help to ensure model fidelity, consistency, and coordination of home visiting statewide. The proposed enhanced program will be integrated into this already existing system and will build on our highly trained, highly skilled Maine Families workforce. Through Maine s 2010 Needs Assessment and follow-up meetings (including conversations with Maine Families and Public Health Nursing home visiting administrators statewide), we have determined a high degree of readiness, buy-in, and capacity to implement the enhanced program. The proposed program responds to specific requests around continued commitment to the PAT model and Touchpoints approach, improved clinical support for home visitors, and improved coordination of services among diverse providers. The proposed work plan, which outlines a gradual year-by-year expansion of direct service staff, was developed in close consultation with program sites. The Maine Families State Coordinator spoke with program managers to identify realistically how many staff could be added without compromising fidelity to the PAT model or quality of service. The resulting numbers are based on careful consideration by local providers regarding their own capacity for expansion. In addition, Maine s proposed Linking activities build on the successes and lessons learned from two pilot communities within the state. Washington County s Bridging Project is led by the Community Caring Collaborative (CCC), a coalition of 35 agencies, and is the recipient of a LAUNCH grant from the federal Substance Abuse and Mental Health Services Administration. The Linking model is currently being replicated in the Penquis region (Penobscot/Piscataquis Counties) as part of our MIECHV Updated State Plan, and would be taken statewide as part of the MIECHV Expansion. The success of the model in Washington County and lessons learned 12 BRFSS m US Census 2009 Population Estimates Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

10 from the newly piloted initiative in the Penquis region will further add to Maine s capacity and readiness to expand inter-agency collaboration efforts statewide. Estimated number of families that will be reached by this project The following estimates were developed by gathering feedback from provider sites regarding how fast they could grow and still maintain quality and fidelity: Year 1: Up to 25 new direct service positions and 5 supervisory positions will be added to serve an estimated 700 families per year. Allowing 6 months for hiring, training, and orientation, about half (350 new families) would be served by the end of the first year. Year 2: Up to 15 new positions will be added to serve an estimated 400 families per year. Allowing 6 months for hiring, training, and orientation, about half (200 new families) would be served by the end of the second year. ( =900 families served by MIECHV Expansion in Year 2.) Years 3 & 4: In Year 3, program eligibility will be expanded to include families with children ages 3-5. Up to 15 new positions will be added each year, to serve an estimated 400 families per year. Allowing 6 months for hiring, training, and orientation, about half (200) would be served by the end of the first year. ( =1300 families served by MIECHV Expansion in Year =1700 families served by MIECHV Expansion in Year 4.) How the priority element will reach Maine s desired outcomes for its expansion project Maine has selected Priority Element 7: To reach families in rural or frontier areas through home visiting programs because it encapsulates so many of the public health and systems improvement priorities that are outlined in our State Plan. In our 2010 Needs Assessment, home visiting stakeholders in each of Maine s 16 counties reported challenges around engaging isolated, rural families. The MIECHV Expansion will assist Maine in reaching its goal of reaching more families in rural areas by providing resources to enhance services, increase staffing and travel resources, and increase local collaboration among early childhood providers so that more rural families can be reached, and isolated families can be better engaged. METHODOLOGY Model selection Maine has selected Parents as Teachers as our evidence-based home visiting model. PAT has been offered in some Maine counties since the late 1990 s. Maine has implemented the program statewide since 2008, following rigorous standards of practice to ensure fidelity. We received approval of our MIECHV Expansion implementation plan from the PAT developers in a letter dated 6/22/2011 (see Attachment 8). The letter includes approval of the following proposed enhancements: Continued use of the Touchpoints approach of reflective practice and reflective supervision, and the framework of protective factors. These are all enhancements to the PAT model that Maine has had in place for some time now, and many of these elements have already been incorporated into the PAT model. Provision of additional training and clinical supervision for home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, cooccurring needs, and family violence issues. Resources to allow for greater frequency of home visits to highest-risk families. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

11 Support for strengthening local efforts to build coordination and collaboration among service providers to better serve families in need. Purpose, Goals and Objectives Maine s MIECHV Expansion will serve to strengthen, enhance, and expand the state s existing statewide home visiting program, Maine Families, as part of a comprehensive early childhood system. While Maine already has a solid statewide network of Maine Families sites implementing Parents as Teachers and following rigorous standards of practice, the state needs additional resources in order to: 1. Reach greater numbers of eligible families (including: those with needs related to substance abuse, mental health, co-occurring disorders, and/or family violence, those in rural areas, and those living in tribal communities). 2. Better serve vulnerable families through enhancement of the PAT program that includes provision of more frequent visits to families who need them; additional training and clinical supervision for home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, co-occurring, and/or family violence issues; and strengthening of coordination and collaboration among local service providers to better serve families in need. For the purposes of this application, these collective efforts are termed the Maine Families Linking Initiative. 3. Increase capacity of all Maine Families sites to participate in data collection and reporting according to federal Benchmark requirements. 4. Strengthen state-level systems collaboration to build a coordinated continuum of early childhood services, with home visiting as a sustainable and integral component of that system. The goals and objectives of Maine s MIECHV Expansion, as outlined in our Logic Model in Attachment 1, are as follows: Short term objectives More eligible families served. Increase in participants identified with substance abuse, mental health, co-occurring, and/or family violence issues. Increased enrollment and participation of families living in rural areas and families living on reservations. Maintained PAT program fidelity. Maintained high retention rates for participants. Maintained high rates of participant satisfaction with the program. Maintained high retention rates for staff. Increased staff competency and comfort in addressing issues facing vulnerable families. Increased screening and referrals to needed services. Increased collaboration, formalized agreements, and shared tools/systems among local agencies to better serve vulnerable families. Data collection system enhanced to meet federal requirements. Formalized agreements among state agencies, e.g. program roles within continuum of services, staff competency standards and training plans, and consistent use of data to inform policy and services. Medium term objectives Increased participant knowledge and understanding of maternal and infant health, safety and parenting Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

12 Increased number of vulnerable families who receive needed services (e.g. services for substance abuse, mental health, co-occurring, and/or family violence issues) Benchmarks data routinely submitted to federal government and used for program evaluation Measurable progress in the MIECHV Benchmark: Improved Coordination and Referrals for Community Resources/Supports Documented collaborative initiatives between state agencies to provide a continuum of support to families Public and political will for sustained funding of home visiting programs and infrastructure Long term objectives Measurable progress in the MIECHV Benchmarks and associated constructs: Improved maternal, infant and child health Reduced child maltreatment and injuries Improved school readiness and achievement/positive parenting practices Reduced/prevented domestic violence In addition, the goals and objectives in our MIECHV Expansion logic model are aligned with the Parents as Teachers goals and objectives, outlined below. Parents as Teachers Goals Provide early detection of developmental delays and health issues Increase parent knowledge of early childhood development and improve parenting practices Short Term Intermediate Long Term Increase in healthy pregnancies and improved birth outcomes (when services are delivered prenatally) Early detection of developmental delays and health issues Children will have increased identification and referral to services for possible developmental delays and vision/hearing/ health issues Increase in parent s knowledge of their children s emerging development and age-appropriate child development Parents are knowledgeable about their child s current and emerging language, intellectual, social-emotional, and motor development Parents recognize their child s developmental strengths and possible delays Parents are familiar with key messages about healthy births, attachment, discipline, health, nutrition, safety, sleep, and transitions/routines Improved parenting capacity, parenting practices, and parent-child relationships Parents understand that a child s development influences parenting responses Parents display more literacy and language promoting behaviors Improved child health and development Strong communities, thriving families, and children who are healthy, safe, and ready to succeed Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

13 Parents as Teachers Goals Increase children s school readiness and school success Prevent child abuse and neglect Short Term Intermediate Long Term Parents demonstrate positive parenting skills, including nurturing and responsive parenting behaviors and positive discipline techniques Parents show increased frequency, duration, and quality of parent-child interactions Increased parent involvement in children s care and education Improved family health and functioning Improved quality of home environment Families link with other families and build social connections Parents are more resilient and less stressed Parents are empowered to identify and utilize resources and achieve family and child goals Families are connected to concrete support in times of need Increased school readiness Prevention of child abuse and neglect Details of our evaluation plan are included in the section, Evaluation and Technical Support Capacity on page 34. Strong communities, thriving families, and children who are healthy, safe, and ready to succeed STRENGTH OF EVIDENCE Maine has selected Parents as Teachers (PAT) for four reasons: (1) our state s demonstrated capacity and track record of implementing the program successfully all 16 counties; (2) its fit with community needs and program goals; (3) its strong evidence base; and (4) demonstrated positive outcomes for families in Maine. Each of these points is described in detail below. Maine s experience with PAT: PAT has been an integrated part of Maine home visiting programs for many years. Maine committed to fully adopting PAT for all state-funded Maine Families sites three years ago as our system of home visiting became more coordinated; it was incorporated as a requirement in the Standards of Practice. Maine s statewide network of home visiting providers already have a strong track record of success implementing PAT, a solid administrative infrastructure, and PAT-trained staff in place. A high level of collaboration and coordination already exists among diverse local agencies and providers. Maine has a well-established state-level infrastructure and capacity to support PAT implementation with fidelity, including a centralized online data system and a statewide Quality Assurance and Technical Assistance Specialist to monitor and implement quality assurance standards. Maine has a PAT training team located in-state. Currently, Maine has 100 home visiting staff trained and certified in the PAT model. We completed Foundational retraining for all home visitors and Implementation training for all managers and supervisors this year. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

14 Maine will be able to implement swiftly the activities necessary for implementation, making effective use of federal and state dollars immediately with limited start up costs or time needed. Local conditions and capacities that increase the likelihood of success In addition to Maine s established infrastructure, capacity to implement the program, and promising evaluation outcomes, PAT is a strong fit for Maine for the following reasons: Community needs: The Parents as Teachers Curriculum is designed specifically to support communities with the needs identified in Maine including poverty, high rates of high school dropout, child maltreatment, domestic violence, and substance abuse. The PAT curriculum includes specific modules designed to meet family needs related to low-income, low family or student academic achievement, history of substance abuse or need for substance abuse treatment, history of child abuse or neglect, and families who have experienced child abuse and neglect. Provider buy-in: PAT was selected because it was a national model that most program sites were already partially invested in. Maine providers preferred PAT because it was regarded as a more strength-based, has a more respectful approach than other models, and was a fit with Maine communities and programs' philosophy. Today, as the PAT developers have revamped and updated their curriculum and training, the fit is even stronger. The updated PAT curriculum incorporates a stronger focus on reflective practice and supervision, a curriculum that lends itself to greater individualization for each family and incorporates the Strengthening Families 13 Protective Factors which also aligns with the state s Strengthening Maine Families project working with childcare providers. Family satisfaction: Families consistently report high levels of satisfaction with the program. Each year, Maine Families participants have the opportunity to respond to an anonymous survey about their experiences in the program. In the 2010 survey, 97 percent of the responding families reported they are very satisfied with their home visitor; 97 percent said their home visitor was very well trained; 99 percent reported their home visitor understood their needs and treated them very well; and nearly 100 percent indicated that their home visitor was respectful of their culture or background. Self-reported family outcomes: In addition, the vast majority of surveyed families report positive impacts resulting from their participation in the Maine Families. In the 2010 survey, 92 percent of responding families reported a moderate to great increase in their confidence as a parent; 88 percent reported a moderate to great increase in their knowledge of caring for babies; and 95 percent reported a moderate to great benefit to their children resulting from participation in the program. Fit with Maine goals: Maine s programmatic goals are constructed to match those of our selected evidence-based program model, Parents as Teachers, as outlined above. The four PAT overarching goals are: a) Provide early detection of developmental delays and health issues; b) Increase parent knowledge of early childhood development and improve 13 Strengthening Families is an evidence based approach to child maltreatment that focuses on working with providers of early care and education to improve the protective factors known to mitigate the risk of child abuse and neglect. More information on this national program can be found at the Center for the Study of Social Policy website: and details about Maine s program can be found online at Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

15 parenting practices; c) Increase children s school readiness and school success; and d) Prevent child abuse and neglect. As described above, evaluation of the Maine Families program already demonstrates promising outcomes toward achieving these goals. Fit with Maine theoretical framework: The PAT Theoretical Framework is already integrated throughout the Maine Families Standards of Practice. Maine Families parent educators share research-based information and utilize evidence-based practices by partnering, facilitating, and reflecting with families. Parent educators use the PAT Foundational Curriculum in culturally sensitive ways to deliver services that emphasize a) Parent-child interaction; b) Development-centered parenting; and c) Family well-being. In addition, Maine Families follows these Core Values as outlined by PAT: o The early years of a child s life are critical for optimal development and provide the foundation for success in school and in life. o Parents are their children s first and most influential teachers. o Established and emerging research is the foundation of our curriculum, training, materials and services. o All young children and their families deserve opportunities to succeed, regardless of any demographic, geographic, or economic considerations. o An understanding and appreciation of the history and traditions of diverse cultures is essential in serving families. Evidence of effectiveness There is a solid body of evidence that supports the selection of Parents as Teachers as the evidence-based model of home visiting for Maine. In its review of 16 published evaluations of the Parents as Teachers program, the Home Visiting Evidence of Effectiveness (HomVEE) Study determined favorable impacts in two domains: Child Development and School Readiness, and Positive Parenting Practices. In addition, the 2011 Parents as Teachers Foundational and Model Implementation curriculum and training have been strengthened to incorporate research findings and recommendations. And as we will show, Maine s implementation of the PAT program has had promising outcomes related to physical and emotional health, school readiness, reducing the risk for child abuse/neglect, and increasing family self-sufficiency. Summarized below are the important components about PAT s evidence of effectiveness: study design quality, substantive impact for families served, duration of findings, replication of findings, quality of measures, the presence of null/ambiguous findings, and the independence of the evaluator. 1. Study design quality As a network of home visiting programs, Maine Families is grounded in Parents as Teachers (PAT), one of seven models meeting evidence of effectiveness criteria in the HomVEE review of home visiting program effectiveness. The PAT program model meets the US Department of Health and Human Services (DHHS) criteria for an evidence-based early childhood home visiting service delivery model because there are at least 2 high or moderate quality impact studies using different samples with 1 or more favorable, statistically significant impacts in the same domain. At least 1 of these impacts is from a randomized controlled trial and has been published in a peer-reviewed journal. At least 1 of the favorable impacts from a randomized controlled trial was sustained for at least a year after program enrollment. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

16 The following information, excerpted from the HomVEE website 14, provides a summary of study design quality of the research used by HomVEE to review PAT evidence of effectiveness. The HomVEE review identified 49 studies of PAT published between 1979 and Of these, 16 studies were eligible for review: 2 received a high rating; 2 received a moderate rating; 8 received a low rating; and four were additional sources, which overlap with other studies, and were not rated. Across the studies that received a high or moderate rating, four samples were used in the research. The following PAT impact studies were rated high for their randomized control trial design, low attrition, and lack of reassignment or confounding factors: Impact Studies Rated High Citation Design Attrition Baseline Equivalence Reassignment Confounding Factors Drotar, D., Robinson, J., Jeavons, L., & Lester Kirchner, H. (2009). A randomized, controlled evaluation of early intervention: The Born to Learn curriculum. Child: Care, Health & Development, 35(5), Randomized controlled trial Low Not applicable None None Wagner, M., Clayton, S., Gerlach- Downie, S., & McElroy, M. (1999). An evaluation of the northern California Parents as Teachers demonstration. Menlo Park, CA: SRI International. Randomized controlled trial Low Not applicable None None The following Impact Studies were rated moderate. These also used randomized controlled trial, but had high attrition: Impact Studies Rated Moderate Citation Design Attrition Baseline Equivalence Reassignment Confound -ing Factors Wagner, M., & Spiker, D. (2001). Experiences and outcomes for children and families: Multisite Parents as Teachers evaluation. Menlo Park, CA: SRI International. blications/humanpub/patfinal.pdf. Randomized controlled trial High Established on race/ethnicity, SES, and mother s mental health. None None Wagner, M., Cameto, R., & Gerlach-Downie, S. (1996). Intervention in support of adolescent parents and their children: A final report on the Teen Parents as Teachers Demonstration. Menlo Park, CA: SRI International. Randomized controlled trial High Established on race/ethnicity, and SES. Lack of equivalence on baseline contraceptive use and experience with infants. Yes None 2. The substantive impact for the individuals served; Taking into account all of the review results as of January 2010, which include all high- or moderate-quality impact studies for this program model, the HomVee study determined that the PAT program model has 5 favorable impacts and 7 unfavorable or ambiguous impacts. The 14 retrieved 6/17/2010 Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

17 HomVee study determined PAT had favorable impacts in two domains: Child Development and School Readiness, and Positive Parenting Practices. The favorable impacts 15 were as follows, all primary outcome measures: Child Development and School Readiness DPII Self-Help Development Scale (mean months differential) - Northern California sample, 3 year follow up (Wagner et al, 1999) Mastery Motivation Task Competence- Ohio sample, 36 month follow up (Drotar, et al, 2009) Positive Parenting Practices HOME total scale teen mothers sample, 1 year follow up (Wagner, et al, 1996) HOME parental responsivity subscale teen mothers sample, 1 year follow up (Wagner, et al, 1996) HOME appropriate play materials subscale teen mothers sample, 1 year follow up (Wagner, et al, 1996) 3. Duration of findings, replication of findings; The HomVEE review determined that none of the favorable impacts were sustained longer than a year after the end of the program, but at least one favorable finding was replicated in a study of similar quality using a different sample. 4. Quality of measures on which impacts were obtained; Mastery Motivation Task Competence was measured using three sets of toys: puzzles, shape sorters and cause and effect; assessed at 12, 24 and 36 months (Drotar, et al, 2009). The Developmental Profile II (DPII) (Alpern et al, 1986) 16 uses cognitive, communication, social development, self-help, and physical development scales. On a scale of 1 to 3, the US Department of Health and Human Services Administration of Children and Families (ACF) Office of Research, Planning and Evaluation gives the tool a Score of 3 for reliability (.65 or higher ) and 2 for validity (Under 0.5 for concurrent; under 0.4 for predictive). 17 The Home Observation for Measurement of the Environment (HOME) Inventory for families of children ages birth to three (Caldwell & Bradley, 1984) 18 assesses parenting practices using the following subscales: acceptance of child s behavior, opportunity for stimulation, organization of the environment, parental involvement, parental responsivity, and appropriate play materials. The HOME is based on parent reports and field evaluator observations. On a scale of 1 to 3, the ACF Office of Research, Planning and Evaluation gives the tool a Score of 2 for reliability (under.65) and 2 for validity (Under 0.5 for concurrent; under 0.4 for predictive) Presence of null effects or unfavorable/ambiguous findings, and evaluator independence Based on its review of the studies listed above, the HomVee study determined that the PAT program model has 7 unfavorable or ambiguous impacts. The following unfavorable or ambiguous impacts were identified: Alpern, G., Boll, T., and Shearer, M. Developmental Profile II. Los Angeles: Western Psychological Services, retrieved 6/20/ Caldwell, B.M., and Bradley, R.H. Home Observation and Measurement of the Environment.Little Rock, AK: University of Arkansas at Little Rock, retrieved 6/20/2011 Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

18 Positive Parenting Practices HOME acceptance of child s behavior subscale Northern California sample, 2 year follow up (Wagner et al, 1999) HOME acceptance of child s behavior subscale Northern California sample, 3 year follow up (Wagner et al, 1999) Discipline (from HOME items) - Northern California sample, 3 year follow up (Wagner et al, 1999) HOME appropriate play materials subscale teen mother sample, 2 year follow up (Wagner, et al, 1996) Child Development and School Readiness DPII Social Development Scale (mean months differential)-northern California sample, 2 year follow up (Wagner et al, 1999) Family Economic Self-Sufficiency Household income $30000 or more- Northern California sample - 3 year follow up (Wagner, et al, 1999) Married - Teen mothers sample - 2 year follow up (Wagner, et al, 1996) How PAT will improve outcomes for the focus population consistent with Maine s goals The evidence above suggests that Maine s implementation of PAT would produce positive outcomes in Child Development/School Readiness and Positive Parenting Practices. However, as Maine has implemented PAT statewide since 2008, we have our own evidence that the model will produce results in our state. Maine s own impact data, collected for 2,500 families participating in Maine Families annually as part of the evaluation we have had in place for nine years, shows promising impacts in the following areas 20 including areas identified as potentially problematic in the HomVEE study (positive parenting, economic self sufficiency). Domain Child Development and School Readiness Child Health Maine promising outcomes per 2010 data from Maine Families implementation of PAT: Of all eligible children in the program, 83 percent were routinely screened for developmental delays. Seven percent of those screened were referred for further evaluation, and as a result 72 percent of those children initially referred through home visiting now have a formal plan and services to address developmental issues. 99.5% of enrolled children had an identified Primary Care Provider (PCP). 98% were up to date with well-child check-ups. 95% of children had health insurance. 93% of children had up to date immunizations (Maine rate 72.3%). 44% of the children who were exposed to second-hand smoke are no longer exposed and 28% have reduced exposure. 20 Reductions in Family Violence outcome data is not available. Family violence is one arena that it has been difficult for Maine Families to track accurately, as data entry only represents families for whom it would be considered safe to have data in the record. In cases when both parents sign the participation agreement, they both have access to records so great care is used when recording anything related to DV. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

19 Domain Family Economic Self- Sufficiency Linkages and Referrals Maine promising outcomes per 2010 data from Maine Families implementation of PAT: Of the enrolled parents who entered the program without a high school diploma, 94% subsequently earned a HS diploma or GED. Of the enrolled parents seeking employment, 91% achieved employment. Maine Families staff made more than 23,000 referrals on behalf of families in FY Surveyed families reported that having a home visitor to help them make these connections is a significant benefit of their participation in the program. Nearly all enrolled families had adequate food and heat in their homes, facilitated in part by referrals of assistance to those in need. Maternal Health 94% of enrolled expectant mothers received adequate prenatal care (Maine rate 85%). Positive Parenting Practices Reductions in Child Maltreatment 92% of families surveyed expressed a great to moderate increase in their confidence in parenting. Additionally, 63 percent said their child greatly benefits from participation in the program. 1% of children in enrolled in the program were victims of substantiated abuse or neglect (Maine rate 2.4%). It is also important to note that Maine Families implementation of the PAT is consistent with broader research recommendations and evidence-based practices. According to Shonkoff, et al. (2007) early childhood education programs delivering significant return on investment have four common elements: targeted service populations, integrated programming, quality standards, and outcome-based program evaluation. 21 The Maine Families home visiting program is consistent with each of these elements. Maine Families sites follow rigorous Standards of Practice that include stringent education and training requirements for home visitors. Maine has an established state-level infrastructure and capacity to support fidelity, including an in-state PAT training team, centralized online data system, and a statewide Quality Assurance and Technical Assistance Specialist to monitor and implement quality assurance standards. Use of the Touchpoints model of reflective practice and supervision, ongoing needs assessment, CQI and performance-based contracting guide all project activities. Maine also has a strong track record of community collaboration, which is especially important in rural areas. All these mechanisms help to ensure that PAT implementation will result in desired outcomes. Maine s proposed expansion of PAT will help to further build on recommendations drawn from PAT research. According to reports submitted to the Robert Wood Johnson Foundation (RWJF) by the Parents as Teachers National Center and their independent evaluator, SRI: PAT is most effective when it is part of an umbrella of social services. 22 Our MIECHV Expansion will help to increase collaboration on both a local and statewide level in order to ensure that home visiting is operating as part of a comprehensive and coordinated system of services. 21 Shonkoff, J. et al. (2007). The Science of Early Childhood Development. National Scientific Council on the Developing Child. Retrieved from Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

20 In addition, as noted earlier, the 2011 PAT curriculum and training have been strengthened to address challenges identified in the HomVEE study. Components include an increased focus on evidence-based practices, family well-being factors, Strengthening Families protective factors, parent goal setting, intentional reflection, parent educator core competencies, and new tools including parent-child activity pages, parent educator tool kit, and an enhanced prenatal section. As a PAT implementation site, Maine will continue to participate in national PAT evaluation. WORK PLAN Maine s proposed MIECHV Expansion Project has been thoughtfully constructed around four key activities: Direct Service Delivery, Infrastructure Support, Community Collaboration, and Sustainability. Direct service activities include increasing home visiting capacity to serve more vulnerable families and to implement the enhanced (and approved) PAT model (see PAT Letter of Approval in Attachment 8). Infrastructure activities include evaluation, data collection and analysis/benchmark reporting, professional development, continuous quality improvement and technical assistance. Community collaboration activities are structured to meet the intent of the federal legislation, which includes involving stakeholders in facilitated dialogue and workgroups to address systems issues related to serving young children and their families, with continued use of the Zero to Three State Home Visiting Assessment Tool. Sustainability activities address ongoing financing of home visiting from multiple angles at the onset of the project: building public will with effective social marketing (already welldeveloped by the state early childhood advisory council), capitalizing on technical assistance from the Build Initiative and the Urban Institute to examine Medicaid regulations that inhibit effective state and local match of federal dollars, reporting to the Legislature as per state statute (LD 1504) on the home visiting state plan progress, working with our Congressional Delegation who view sustainability as not only a state, but federal issue, and continuing our constant quality assurance to identify inefficiencies and cost savings that drain direct service budgets of all home visiting and home based programs. A detailed implementation timeline is included as Attachment 7. DIRECT SERVICE ACTIVITIES 1. Increase Maine Families staffing (trained home visitors) to reach greater numbers of eligible families. During the first three months of the project, the Maine Families State Coordinator will work together with local sites to hire new staff (25 home visitors, and up to five new supervisors) and set up a training schedule for this first cohort of new hires. The next three months will be dedicated to Maine Families orientation, PAT training and certification, and Touchpoints Individual Level Training. As capacity grows over the next six months, experienced home visitors will enroll 2-3 new families each while continuing to serve existing families. New home visiting staff will build family loads toward full capacity. The second year will follow a similar process to hire and train the next cohort of 15 additional new staff. We anticipate that Years 3 and 4 will follow a similar pattern of moderate expansion as informed by local need and demand for home visiting services. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

21 Beginning in Year 3, we will train all Maine Families staff for PAT certification for families with children ages 3-5, and expand program eligibility to serve children up to their fourth birthday. Following this gradual expansion process, with each year building on capacity developed during the previous year, we anticipate that Maine Families will be reaching an additional 1700 families annually by the end of the project. 2. Enhance implementation of PAT model program to better link families to needed services, i.e. Linking Initiative. While local sites work to hire and train new staff and serve greater numbers of eligible families, they will also receive support to better link families to needed services. Increased staff hours will allow sites to provide more frequent visits to families who need them. Increased clinical supervision and specialized training (which will be offered jointly to home visitors and their community partners) will help to better prepare them for engaging and assisting families with substance abuse, mental health, co-occurring, and family violence issues. This portion of the Linking Initiative will be led by the Maine Families Statewide Coordinator. The MIECHV expansion will also support local staff time to participate in coalition-building efforts to better serve families with high needs. In Year 1, local agencies will work together with Maine s MIECHV Collaboration Specialist, Maine Families Coordinator, and MIECHV Evaluation Team to assess their current collaboration levels and identify next steps. Work plan activities will likely differ from county to county, as they will be dictated by level of community readiness and existing collaboration capacity. Throughout the duration of the MIECHV Expansion program, local Maine Families sites will work to build formal partnerships among hospitals, public health nursing, community health nursing, substance abuse treatment facilities and others to create improved referral systems and protocol to ensure that families are getting what they need. The MIECHV Collaboration Specialist will provide technical assistance and coaching to communities as needed to assist agencies in coalition-building and building formal collaborative relationships. Technical assistance will utilize tools and lessons learned from Maine s Linking pilot communities, including sample documents such as MOU s, universal intake forms, and joint marketing materials. Following this process, with each community receiving coaching tailored to their individual readiness, capacity, and priorities, we anticipate that every Maine Families site (12 sites serving Maine s 16 counties) will have a solid coalition and formal agreements in place by the end of the project. INFRASTRUCTURE 1. Work with evaluator to develop and maintain statewide and local level data collection, reporting, and analysis according to federal Benchmark requirements. Evaluation of Maine s MIECHV Expansion Grant will be conducted by an evaluation team at the University of Southern Maine. Details of the evaluation work plan are included in the Evaluation section. Part of the evaluation team s task will be to ensure that grant-required benchmark data are collected from each agency. The evaluation team will be responsible for overseeing enhancement of the Maine Families online data system to include the required benchmark data. The Maine Families Coordinator will organize any training needed for Maine Families staff to collect and report additional data points (for example, how to use any additional screening tools). Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

22 Benchmark data will be compiled into an annual report that will be available to Maine Families agencies, as well as key collaborators and the public, to help them understand program outcomes and the needs of families served. In addition, we have budgeted for Office of Information Technology staff to help identify the most efficient ways to host, house and connect data sets across partnering state agencies. 2. Assemble the CQI/Evaluation Team. A joint CQI/Evaluation team will be formed to include the State Administrator and Coordinator, the MCH epidemiology/evaluation team, site managers and home visitors, data management staff and partners. The State Administrator and the Maine Families State Coordinator (QA/TA Specialist), along with appropriate members of the CQI team, will review quarterly data with staff from each site. Data reports will also be reviewed by the CQI team at the community, regional, and state levels to inform systems-level change. 3. Ensure necessary professional development opportunities are in place for all programs in the home visiting continuum of services. The Maine Families Coordinator will continue to monitor and coordinate the professional development of home visitors to ensure compliance with PAT and the State Standards of Practice.This includes PAT training, Infant Mental Health Training, Maine Core training, Great Beginnings Training and Touchpoints Training and mentoring, as well as a great deal of wraparound training. We will explore expanded use of the Home Visiting Track of the Maine Roads to Quality Registry for Early Childhood Professionals to include all home visitors along the continuum of services. COMMUNITY COLLABORATION 1. Work with consultant/facilitator and supporting state staff time to build a coordinated continuum of early childhood services statewide while strengthening the long-term sustainability of Maine s home visiting system. The MIECHV Expansion program will advance Maine s statewide systems coordination and sustainability by supporting staff time and facilitation to make it happen. The MIECHV Collaboration Specialist will be responsible for serving as a neutral convener and coordinating a series of statewide work groups on behalf of the Maine Children s Growth Council. Work group participation will be voluntary, and it will be the facilitator s task to ensure broad representation and engagement from local and state level stakeholders. Based on the work done in the planning year of the federal MIECHV project around the needs assessment and state plan development, the following topics have been identified by stakeholders as priorities for the initial work group agenda: Program Definition and Standards, Training and Professional Development, Coordinated Data and Evaluation Systems, Quality Assurance, and Financing/Sustainability. As the work progresses, additional topics will be selected based on group interest and/or direction from the Maine Children s Growth Council. The work will be guided by priorities outlined in Maine s State Plan as well as tools available from national resources such as Zero to Three. The work will also be coordinated with other state-led coalition efforts, such as Maine s Drug Affected Baby Symposium and new Fetal Alcohol Spectrum Disorder planning group. Work groups will meet via conference call at least monthly to address selected topics and develop joint recommendations. To promote high levels of participation, only one topic/work group will be convened at a time for example, the Home Visiting Definition and Standards work group may require 3-6 months to reach consensus and finalize its recommendations. A Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

23 new meeting invitation will be issued each time a new topic begins, to ensure that those with interest in a particular topic are engaged. The work group process will use a consensus-building model, resorting to vote only when the group deems it necessary. Recommendations will be presented to the Maine Children s Growth Council for review and decision-making. We anticipate that the work groups will cover at least three topics per year, with some overlap between years. In addition, the MIECHV Collaboration Specialist will develop template documents to support coalition building, such as standard referral forms or MOUs. 2. Provide financial support to major statewide partners in recognition of the value of their participation in the home visiting systems improvement workgroups. From our years of systems building work in early childhood, we have learned that one of the greatest challenges to engaging and maintaining active participation is that families still need services while providers are taking the time to improve how those services are delivered. The Maine MIECHV Expansion proposal budget includes financial resources to pay for the time of our key partners, including, but not limited to public health nursing (at the state leadership and local service levels), the PreK Collaboration Coaches, the Community Caring Collaborative (the original LAUNCH Linking Initiative creator), and early care and education providers. Based on the preponderance of data indicating need for increased coordination to serve families affected by substance abuse, this project will also fund a position at the Office of Substance Abuse for a Fetal Alcohol Spectrum Disorder (FASD) Coordinator (a brief job description is included in Attachment 2.) Attachment 4 highlights the kinds of formal (contractual) and informal (collaborative) partnerships secured with major partners in this expansion project. 3. Invest in the professional development infrastructure eliminating the cost barrier so that all child and family serving disciplines are able to participate in community-based training in Touchpoints, PAT, and other interdisciplinary topics. Several years ago, at the direction of the Governor s Children s Cabinet, Maine put together a Touchpoints Training Team for community providers of services to young children and their families. That team began working with the network of home visiting programs first in order to best understand how to implement with sustainability and take to scale an approach that would effectively improve practice across disciplines and employ a common language and philosophy for partnering with parents. Our evaluation of our Touchpoints project gave us a solid footing on how to take this approach to scale statewide and across disciplines. The Maine Touchpoints Team has been recognized by the Brazelton Touchpoints Center for its success with home visiting and our state Touchpoints Coordinator is now a member of the BTC Senior Faculty, providing training across the county as part of the BTC Team. This expansion project budget support the costs associated with the training team growth as well as the community level training, mentoring and reflective supervision. SUSTAINABILITY 1. Build public will for continued and increased public and private investment in home visiting as an effective and accountable component of the early childhood system. With funding from the Nellie Mae Education Foundation, the Maine Children s Growth Council launched a successful multi-faceted communications campaign from to build public Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

24 will among Maine s public and policymakers. The campaign specifically targeted Maine business leaders, Legislature, philanthropy and the general public with messages about the importance of early childhood investment. Outcomes included greater awareness of the Council s priorities during the state budgeting process, recognition of an early childhood voice within the newly elected Governor s office and newly appointed Commissioners of Education and Health and Human Services, development of a philanthropic Early Childhood Funders Group and a business CEO-led Early Learning Investment Group, cohesion among the myriad early childhood systems providers and advocates, and public education on brain architecture and toxic stress. Research has shown that just as media-related commercial marketing aimed at promoting the purchase of products has been associated with negative health consequences (such as poor nutrition and physical inactivity), social marketing campaigns aimed at positive values can be equally as effective. W. Douglas Evans, noted researcher and author, outlines the benefits of social marketing in the Princeton University Brookings Institute publication, The Future of Children (Vol. 18, No.1, pp , spring 2008). Evans argues that, like commercial marketers, social marketers create value for target audiences through their own form of branding- --by creating positive associations with health behaviors and encouraging their adoptions and maintenance. Marketing of home visiting will lead to sustainability of the Maine Families program. The Council will apply well-organized and tested social marketing strategies to (1) Improve child and family outcomes with reinforced messaging about the value of participating in quality care childhood programs like home visiting and (2) Address sustainability with sharply focused efforts to build public will among policymakers, business leaders, and philanthropy. Components of the campaign will include (a) daily facts distributed to the Legislature on the value of home visiting and the needs of vulnerable children and families in at-risk communities; (b) training/technical assistance on messaging for the network of home visiting programs utilizing the most current research on effective framing of home visiting importance; (c) development and distribution of collateral materials such as banners, posters, bumper stickers, and brochures to reinforce public sentiment; (d) development and purchase of broadcast time for 30-second TV ads as well as coordination of earned media time; (e) partnership activities with America s Edge, Mission Readiness, and Fight Crime:Invest in Kids/Maine to publish letters to the editors and Op Eds throughout Maine supporting Maine Families and early childhood issues; (f) promotion of well branded Maine Families identity including the use of social media; and (g) tracking and measuring various communications activities. 2. Leverage technical assistance from the Build Initiative and Urban Institute to examine Medicaid regulations that inhibit effective state and local match of federal dollars. Maine s Office of MaineCare Services (OMS) in the Department of Health and Human Services (DHHS) faces significant challenges as it determines how to make MaineCare (Medicaid) Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

25 funding available for key children s services, including services covered by the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. Maine has experienced recent losses in federal and state MaineCare funding that may be regained, if appropriate technical support is provided. This technical assistance from the Build Initiative and Urban Institute would involve a thorough review of current state MaineCare rules and policies that unintentionally cause barriers for families to access services, with recommendations for changing those rules within federal regulations, based on other state plans around the country that have been approved by the federal government. This funding would ensure that more children receive a broader scope of essential services, particularly through home visiting. Details of the scope of work are included in Attachment 7: Timeline. 3. Communicate regularly with the Executive and Legislative Branches of State Government as well as the Maine Congressional Delegation about the implementation progress of the Maine MIECHV Expansion project. The Governor signed into law LD 1504, a Resolve to ensure a strong start for Maine s infants and toddlers by extending the reach of high-quality home visitation. The Resolve requires the Maine DHHS to develop a comprehensive plan for home visiting that addresses sustainability through diverse funding streams and to report on the plan to the Legislature. Given the history of the Maine Children s Growth Council (originally a Task Force on home visiting), it is not only prudent but practical to also deliver regular progress reports highlighting policy issues with both the Council and the Governor s Children s Cabinet. In that way, public and private input can be discussed on any potential home visiting legislation put forth by the Department. In addition, given the vested interest of Maine s Congressional Delegation in the sustainability of this project (see Letters of Support in Attachment 9), it is important to provide them with updates, so they can extend that public support to the federal level. 4. Continue our constant quality assurance to identify inefficiencies and cost savings that drain the direct service budget. Simply put, our vigilance for good stewardship of public funds has helped us sustain home visiting programming in the past even when we experienced budget cuts. We must continue this activity and encourage our partners to do the same. 5. Use common sense, proven principles of community engagement to help inform, design, implement, and improve the state home visiting plan. The Maine Children s Growth Council, a legislated body of providers, philanthropists, parents, business leaders, advocates, legislators and state agency officials who have held home visiting at the core of their systems work realized early that it could accomplish more by framing its dialogues around agreements. Research on group dynamics and sociology has proven that rehashing issues we disagree on is much less likely to help us move forward and forge new partnerships. The Future Search principles (Janoff, Weisbord, 2005) adopted by the Children s Growth Council in March 2009 will help guide the Maine MIECHV expansion efforts around collaboration, mindful of the need for buy-in as a critical element of sustainability. These principles generally suggest that groups: 1. Have the whole system in the room: if you want plans that are both visionary and practical, you need to have the whole system in the room, meaning people with authority, resources, experience, information and need. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

26 2. Explore global context: if you want action plans based on genuine dialogue and commitment, you must give people a chance to explore the whole before seeking to fix any part--that is, to have everybody talking about the same world, on that includes all of their realities. 3. Focus on common ground: put common ground and desirable futures front and center, while treating problems and conflicts as information, not action items. 4. Self-manage: people manage their own work and take responsibility for acting on what they learn. People discover that they do have the means to change their own lives, and if they don t do it, no one else will. Support and collaboration with key stakeholders Maine s assessment and planning process to date has aimed to engage stakeholders on every level, and has determined a high level of readiness to implement the proposed program enhancements. Maine's 2010 Home Visiting Needs Assessment process was followed by two statewide stakeholder meetings and a series of in-depth one-on-one interviews with stakeholders across the state including local and state-level representatives from Maine Families, Public Health Nursing, Community Health Nursing, and Early Head Start home visiting programs. These meetings clearly pointed to the need for increased coordination not only among different home visiting programs, but also between home visiting and the broader early childhood services structure. In particular, participants emphasized existing gaps around serving families in rural areas and families with substance abuse and mental health needs. The proposed program will work to close those gaps on both local and statewide levels. Highlights of the partnerships within this project are included in Attachment 4: Description of Proposed Contracts. In addition, specific work plan and budget projections for the proposed expansion were developed in close consultation with Maine Families program sites. The Maine Families State Coordinator spoke with program managers to identify realistically how many staff could be added without compromising quality and fidelity to the PAT model. The resulting numbers, which include a gradual year-by-year program expansion, are based on careful consideration by local providers regarding their own capacity for growth. IMPLEMENTATION PLAN Community Engagement Local providers: The Expansion program will provide technical assistance to support countylevel and regional efforts to link together local service providers and develop shared systems and tools. In addition, the program will support staff time by local home visiting providers to participate in these collaborative efforts. Participants will convene meetings on a regular basis to identify areas for increased coordination, develop an action plan, and work together to implement changes. Sample agenda items include improving coordination of outreach, intake, and referrals. Local groups will work to build capacity, expand membership, and establish protocol and Memoranda of Understanding among members. The groups will strive to engage all key partners, including hospitals, pediatric practices, obstetricians, substance abuse clinics, mental health agencies, Early Head Start, Head Start, Cooperative Extension, and other early childhood, child welfare, education, social, and health services. Local groups will utilize lessons learned from the Bridging Project in Washington County and the newer Linking Project pilot program in the Penquis region. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

27 Tribal Communities: As part of the proposed Expansion program, we will explore interest in the expansion of Maine Families home visiting services in Maine s five tribal communities in Aroostook, Penobscot, and Washington Counties. This assessment and planning process will take place in the first year of the MIECHV Expansion. The process will include state staff from the Maine Office of Minority Health, local and state Maine Families representatives, and interested leadership and representatives from the Penobscot Nation, Mi kmaq, Houlton Band of Maliseet, Passamaquoddy at Indian Township, and Passamaquoddy at Sipiyak. State level: The Expansion program will also provide technical assistance and facilitation to support further the statewide systems work that is already underway. Sample work group topics include Home Visiting Definition and Standards, Training and Professional Development, Coordinated Data Systems, Quality Assurance, and Finance/Sustainability based on the Zero to Three State Home Visiting Self-Assessment Tool. Local stakeholders will be invited and encouraged to continue participation in these statewide coordination efforts. Work group participation will be voluntary, with facilitation provided by a neutral convener. Participants include local and state level representatives from Maine Families, Public Health Nursing, Community Health Nursing, and Early Head Start home visiting programs, as well as state staff and other statewide and local stakeholders. Further, as a priority of the Maine Children s Growth Council, there will be continued discussion about home visiting and the expansion project so that the Council can address any systems issues or opportunities as they emerge. Professional development and training plan Maine has a PAT training plan in place as reflected in the Maine Families Standards of Practice. A statewide team of 100 PAT certified home visitors and supervisors is already in place. The selected agencies in the identified communities boast a high retention level and low turnover rates of home visiting staff. All current Maine Families staff have had PAT training, Infant Mental Health Training, Maine Core training, Great Beginnings Training and Touchpoints Training and mentoring, as well as a great deal of wrap-around training. Per the PAT model, ongoing training will build on home visitors core competencies in the following areas: a. Family support and parenting education b. Child and family development c. Human diversity within family systems d. Health, safety, and nutrition e. Relationships between families and communities More in-depth training in substance abuse issues, mental health issues and motivational interviewing will also be provided. The training plan will make the required trainings available as needed to accommodate staff expansion and turn-over. Monitoring, program assessment and support, and technical assistance/cqi plan Maine is committed to a process of Continuous Quality Improvement (CQI) through regular data collection and analysis to inform changes for more effective program implementation and improved participant outcomes. Performance-based contracting is in place now and will continue. Through the collection and regular use of data, Maine s home visiting programs are expected to strengthen programming and document changes and improvements. Data is regularly reviewed at the community and state level to inform systems-level change. This process is Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

28 facilitated with an online database used daily by Maine Families home visitors to record visits. The database will be updated to collect, analyze, and report on all Benchmarks and constructs. The Maine Families State Coordinator serves in the role of Quality Assurance/Technical Assistance Specialist. The Coordinator and evaluators review data with provider agencies to examine successes and needed improvements. The Coordinator provides technical assistance and focuses on quality assurance practices through monthly meetings with Maine Families managers. These meetings have led to deeper understanding of data-informed practice and decision-making, and have provided an opportunity to create relationships that allow for open thinking, support for areas of challenge and the sharing of successful strategies. Sites are reviewed annually and receive immediate feedback on areas of strength and areas to strengthen. The written reviews of sites are shared with the State Administrator to identify systems or policy areas that might need state level modification. Managers provide quarterly narrative reviews per their contracts. An internal comparative report that focuses on performance measures is provided to all sites so that they can view their data relative to others. This report will be expanded to include comparative outcome measures. A CQI team, to be developed with the federal funding upon approval of the Updated State Plan for Home Visiting (and subsequent un-restriction of funds), will help sustain these and new CQI practices in order to further build on the culture of quality that currently exists. The CQI team will include the State Administrator and Coordinator, an MCH epidemiologist, site managers and home visitors, data management staff and partners. The State Administrator and the Maine Families State Coordinator (QA/TA Specialist), along with appropriate members of the CQI team, will review quarterly data with staff from each site. Data reports will also be reviewed by the CQI team at the community, regional, and state levels to inform systems-level change. The full CQI team will meet at least every six months to inform and oversee continuous improvement and to help create a culture of quality throughout as a general expectation. The ongoing assessment of program performance functions not only to improve practice and monitor fidelity, but it provides ample data about the state plan progress in reports to the Joint Standing Committee on Health and Human Services as required in state statute (LD 1504, Resolve to Ensure a Strong Start for Maine's Infants and Toddlers by Extending the Reach of High-quality Home Visitation, signed into law in June 2011 included in Attachment 9). Plan for staffing and subcontracting: Project Director: Sheryl Peavey, Director of the Early Childhood Initiative and appointed Public Health-Child Welfare Liaison, has overall responsibility for state level management and supervision of the Maine Families and MIECHV Programs. She is responsible for grant management and reporting, supervision of subcontracts, and the leadership of statewide efforts to build a more seamless and coordinated statewide early childhood system that includes home visiting. Ms. Peavey is also responsible for staffing and coordination of the Maine Children s Growth Council, which is the state s Early Childhood Advisory Council. Direct Services: The state will contract with existing Maine Families provider agencies for expanded service delivery using an already-established performance-based contracting system. All of these agencies have been providing home visiting services to new families for at least eleven years, and some for many more years than that. Contracts are required to Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

29 comply with policies and standards as outlined in the Maine Families Standards of Practice, which meet or exceed the criteria of the PAT model. For example, Maine Families requires a much smaller supervision ratio, more in-depth training, and a minimum educational level of a Bachelor s degree is required for home visiting staff. All current Maine Families home visiting staff and supervisors have had PAT training, Infant Mental Health Training, Maine Families Orientation, Great Beginnings Training and Touchpoints Training and mentoring, as well as a great deal of wrap-around training. More in-depth training in substance abuse issues, mental health issues and motivational interviewing will be provided as needed. If needed, a more detailed policy will be developed by Maine s TA/QA specialist in consultation with PAT model developers. State Coordinator: Extending its existing contractual partnership, the state will contract with the Maine Children s Trust for the continued services of consultant Pamela LaHaye as Maine Families State Coordinator and QA/TA Specialist. Formerly with the University of Maine, she has worked in the home visiting field since Ms. LaHaye is responsible for state level coordination and provision of training/technical assistance, oversees quality assurance and continuous quality improvement efforts, and serves as liaison with PAT program developers. Clinical Consultants: Three clinical Consultants will be hired by Maine Children s Trust to assist home visitors in better serving families with substance abuse, mental health, cooccurring, and family violence issues. Each consultants will be assigned to work with a subset of Maine Families provider agencies statewide. The Clinical Consultant positions require a Master s degree in social work or counseling, current licensure, experience in providing direct clinical services to over-burdened families with infants/young children, infant mental health training, experience with home visiting programming, and experience and training in reflective practice and reflective supervision, with PAT and Touchpoints training and experience preferred. The positions will report to the Maine Families State Coordinator. Collaboration Specialist: The state will contract with a Collaboration Specialist to facilitate statewide systems coordination and provide technical assistance to local Linking efforts. A potential candidate is Erica Schmitz, Public Health Program Manager at Medical Care Development. Over the past six months, Ms. Schmitz has assisted the Early Childhood Initiative to further the MIECHV planning process by conducting stakeholder interviews, convening work groups, and drafting recommendations. Ms. Schmitz brings more than 12 years of experience in community organizing and coalition-building within the public health arena, and more than 5 years of experience in provision of training and technical assistance for state agencies. She is experienced in bridging multiple demands from state, federal funders, and community stakeholders. Evaluation Team: The evaluation will be staffed by an experienced team of epidemiologists and evaluators from the University of Southern Maine, all of whom have a long-standing partnership with the state s Title V Agency. Please see Evaluation on page 34 for more details. Participant Recruitment and Retention Home visiting providers have established relationships with local agencies to recruit and enroll families prenatally. While informal agreements currently exist among partner agencies, local sites will work to establish formal protocol and Memoranda of Understanding to increase referrals and coordination of services among a broader network of agencies throughout their service regions Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

30 including local hospitals, obstetricians, substance abuse clinics, mental health agencies, and providers of WIC and Head Start services. Our current average retention rate in the Maine Families home visiting program is 1.5 years. We expect that greater frequency of visits plus increased connection with other community services will further help to minimize attrition. Model Fidelity Maine has strong capacity to ensure that the PAT expectations regarding practices and assurances are met. Maine Families has a long-standing relationship with Parents as Teachers, with some sites affiliated with this model since the late 1990s. Maine s fidelity and quality assurance standards already in place follow those of the PAT model: Readiness Reflection, Quality Assurance Guidelines, Essential Requirements, Model Implementation, Training and Guide. Through use of the Maine Families online data system, Quality Assurance is monitored with site level and state level through real time data analysis. The Maine Families State Coordinator serves as the state liaison with the PAT National Office, and is also the program s QA/TA Specialist. Using the Standards of Practice as a guideline, the State Coordinator works closely with program sites to monitor quality and provide TA as needed to ensure fidelity. An in-state training team is already in place. All Maine Families home visitors have already been trained in PAT s new Foundational training and all supervisors have received the Model implementation training. Since Maine has been implementing the PAT model for some time and statewide since 2008 most potential challenges have already been faced and addressed. We will continue to use performance-based contracts to hold sites accountable for both quality and fidelity. Any issues will be identified and addressed quickly by the Maine Families Coordinator, drawing on technical assistance from PAT when needed. As PAT continues to develop their new process for ensuring both quality and fidelity, Maine Families is committed to meeting the new standards. Data collection for legislatively-mandated benchmarks Maine s MIECHV Expansion will support statewide collection of data on legislativelymandated benchmarks. Maine will meet the requirements around quantifiable, measurable improvement in benchmark areas through ongoing data collection and reporting for each of the required six benchmark areas using our existing web-based case management and information system. All home visiting staff have been trained in the use of the database, and are familiar with best practices in observation and documentation of contacts with families. Maine will collect data for all constructs under each benchmark area: improved maternal and newborn health; prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits; improvement in school readiness and achievement; reduction in crime or domestic violence; improvement in family economic self-sufficiency; and improvements in the coordination and referrals for other community resources and supports. Maine will collect data on each participating family rather than use a sampling approach for benchmark areas. The data will be collected for eligible families that have been enrolled in the program who receive services funded with the MIECHV Program funds. To demonstrate improvements in at least four benchmark areas by the end of three years, Maine will show improvement in at least half of the constructs under each benchmark area. Benchmark measures will be utilized for CQI to enhance program operation and decisionmaking and to individualize services. Proposed measures are both developmentally appropriate for the corresponding constructs and appropriate to use with the populations Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

31 served by the home visiting program. To the extent possible, data collected across all benchmark areas will be coordinated and aligned with other relevant State or local data collection efforts. The MIECHV Expansion Project budget includes staffing expertise from the state s Office of Information Technology to ensure a thorough, efficient, and workable approach to coordinating data sets. Maine s Benchmark Plan is outlined in table format on pages of Maine s MIECHV Updated State Plan, which is posted online at These tables contain information for each construct and include the proposed indicator, measurable objective, tool or data source, validity of the source, population being assessed, any special considerations, how the data will be collected, and plans for data analysis. Measure selection and justification: To select appropriate measures for each construct, we began by matching required data with information that is already routinely collected by home visitors and entered into the Maine Families statewide database system. We assessed each required benchmark against the current database system to determine 1) which benchmarks and constructs are captured as required; 2) which are captured but need modification to meet the requirement; and 3) which need to be added. Whenever applicable, we chose measures that are already in place or were identified by our existing CQI process as one to strengthen. For data points that are not already being measured, we reviewed available data collection tools and assessed these for validity/reliability, cost, feasibility, and capacity of staff to implement, as well as potential impact on the family and their home visitor relationship. Final selection of measurement tool was based on a combination of these factors, with the lowest-cost, lowest-risk method selected whenever possible. All selected measures have been reviewed for appropriateness for use with the populations served by the program. Plan for Ensuring Data Quality: Maine s statewide home visiting database for Maine Families is managed by an external evaluator, Hornby Zeller Associates, Inc. (HZA) who has been responsible for the work with Maine Families since Maine Families Home Visitors are certified parent educators with a minimum of a Bachelor s degree and related experience, meet the training requirements of the State Home Visiting Standards of Practice, and are trained in the administration and use of all required tools. All Maine Families home visitors have been trained in use of the database system. The personnel responsible for data management, namely, the maintenance and upgrade of the Home Visiting tracking system, must have a degree and related experience in database design and management. State Administrators and Coordinators, as well as program managers, are required to have a minimum of a Bachelor s degree, working knowledge of all aspects of home visiting program operation, working knowledge of public health strategies and surveillance, and proven experience translating data into functional program improvement actions. Data Safety and Monitoring: The evaluators and direct service providers are trained regarding all rules and regulations protecting the privacy and integrity of the families served, assuring full compliance with federal and state regulations guarding participants from harm, including IRB/human subject protections, HIPAA, and FERPA. In addition, all staff are required to follow best practices in observation and documentation of contacts with families, including sensitive and responsive administration of interviews and screening tools. Staff who work with families in their homes are also trained in identification and mandated reporting of all forms of child maltreatment and neglect. Training for new staff will be provided as needed. Program supervisors are responsible for managing data safety and monitoring on an ongoing basis. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

32 Demographic and service-utilization data: In addition to the reporting requirements for each benchmark area, Maine collects individual-level demographic and service-utilization data on the participants in our program to analyze and understand the progress children and families are making. Individual-level demographic and service-utilization data will include: Family s participation rate in the home visiting program (e.g., number of visits completed/number of scheduled visits, frequency of visits); Demographic data for the participant child(ren), pregnant woman, expectant father, parent(s), or primary caregiver(s) receiving home visiting services including: child s gender, age of all (including age in month for child) at each data collection point and racial and ethnic background of all participants in the family; Participant child s exposure to languages other than English; and Family socioeconomic indicators (e.g., family income, employment status). Data Analysis Plan: Maine s web-based data tracking system allows state administrators and local managers access to real-time data. Data is typically reported in aggregate at county level. Baseline data will be established during year one and finalized at the end of the first project year. During year one and subsequent years, data will be reviewed quarterly by the metrics of each measure based on a data system query. Coordination with appropriate entities/programs Coordination will be led by Sheryl Peavey, Director, Early Childhood Initiative and state-level administrator of the Maine Families program and the MIECHV Project. With MCH funding for early childhood systems, Ms. Peavey staffs and coordinates the Maine Children s Growth Council, the state early childhood advisory council, where she continually refines her community building and organizational development skills to identify new opportunities to improve how Maine supports its young children and their families. Systems coordination is not unfamiliar work for Ms. Peavey. For example, in 2006 Ms. Peavey and the late Tony Morrison, a globally known child protective services consultant, facilitated a three day interdisciplinary conference, Coming Together to Create Family Centered Practice: A Future Search for Child and Family Services in Maine, the results of which are still resonating in local community coalitions across the state. A more recent example of this coordination capacity is how home visiting will now be included in the state Child Care Development Fund (CCDF) plan, as described below. How the Project fits into the State Administrative Structure Ultimately, responsibility of the MIECHV project is shared by two state DHHS entities, OCFS and the Maine CDC, administered by Ms. Peavey. This arrangement has worked for management of the Early Childhood Comprehensive Systems (ECCS) grant, for which the funds are awarded to Maine s Title V Agency (MCDC), and Ms. Peavey is housed at OCFS. Coordination for data collection and an assurance of a public health focus is cemented in a Memorandum of Agreement between the agencies that is reviewed and updated annually. This creative approach has been helping to bridge hierarchical and territorial gaps, and affords a greater level of visibility and accountability for the agencies. It is in this interagency agreement that Ms. Peavey is named the Public Health-Child Welfare Liaison, a role that encompasses other initiatives such as the Safe Sleep Campaign, the Period of Purple Crying (Abusive Head Trauma Prevention), Strengthening Maine Families, Project LAUNCH State Agency Partnership. Incorporating project goals, objectives, and activities into the ongoing work The work to date that Maine has undergone with its home visiting program has been purposefully linked to or a part of the broader state early childhood systems change efforts. Most Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

33 recently, Maine Families Home Visiting has been included in the CCDF State Plan as a partner with the State Office of Child Care and Head Start to assist parents with making informed decisions about quality childcare, provide developmental screens that are intended to be shared with child care and medical providers alike, reinforce the child abuse prevention messaging of the state s Strengthening Families project, and provide additional health promotion resources and connections for early care and education providers. Home visiting has been a part of the sustainability plan for the Community Caring Collaborative of Washington County/Project LAUNCH, and will continue to be. Maine Families Home Visiting has been incorporated into the long-term objectives of the Maine Children s Growth Council since the first edition of the Early Childhood Comprehensive Systems plan, Invest Early in Maine, was published in 2005; it will remain as a priority, particularly as a focus of the Council s Family Committee. Indeed, it is expected that the MIECHV project, which is already guiding an update of the Standards of Practice for alignment of state and federal objectives, will not only be incorporated into the work of partners, it will drive the work of partners. The steps we have taken to date in planning, assessing, and implementation preparation are already helping to inform and guide the state s Race to the Top application, redefine the Office of Information Technology s workplan for data coordination, enhance state capacity to address fetal alcohol spectrum disorders, and potentially dramatically improve the state s use of Medicaid dollars to fund health promotion and other primary prevention activities to promote child and family well-being. The State s Commitment to Home Visiting The drama of this recent legislative session and its budget debate illustrates the resiliency of home visiting to survive intense public scrutiny as well as the state s continued commitment to home visiting. This commitment is assured by more than written promises, it is evidenced by exceptional collaboration, statutory obligation and administrative wisdom. Specifically: The Joint Standing Committee on Appropriations and Financial Affairs presented a unanimous bipartisan recommendation to fully restore funding for Maine Families, despite a looming deficit that will continue to challenge state coffers. The Commissioner of Maine s DHHS has reiterated publicly the administration s intent to stop the costly spending on serving families in crisis and to instead put the funding into proven, accountable programs that prevent abuse and neglect in the first place. The Legislature, in its final budget discussions this June, deliberately chose to diversify the funding streams for home visiting to ensure greater stability with state general funds than the special revenues of the tobacco settlement monies which are subject to market variances. This prophetic move suggests the intent to avoid cuts to the home visiting program in the future. A portion of the restored funding for Maine Families came from child welfare funds, which was a clear statement about investing in strategies to keep children out of child welfare. Another portion of the restored funding came from general funds used as match for the State Child Care Development Fund, recognizing the symbiosis of the home visiting state plan goals with the objectives of the child care plans as co-components of an early childhood system. The language in the state budget specifically appropriates funds for the home visiting program pursuant to the Maine Revised Statutes, Title 22, section 262, that has demonstrated experience meeting state-established home visiting standards of practice for evidence based services Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

34 delivery to intentionally cement the state s vision of aligning its home visiting efforts with those at the federal level. The Maine Children s Growth Council, working with the business and philanthropy communities as part of the ECCS plan, has committed to ensuring that home visiting is a funding priority option for the soon-to-be incorporated business-ceo-led Maine Early Learning Investment Group, which is being created as a means of generating private funds to help support the programmatic goals of the ECCS plan, Invest Early in Maine. The Maine Children s Growth Council has already begun discussions on ways to extend existing tax credits for business investments in child care to include more broadly, all early childhood programs, including home visiting. State officials have agreed to participate in the technical assistance offered by the BUILD Initiative and the Urban Institute to address how state and local funds could better leverage Medicaid dollars in compliance with federal guidelines and the intent of EPSDT. The Governor signed into law a legislative resolve that will ensure a strong start for Maine s infants and toddlers by extending the reach of high-quality home visitation. The Resolve requires the Maine DHHS to develop a comprehensive plan for home visiting that addresses sustainability through diverse funding streams that leverage both cash and in-kind private match wherever possible. Reflecting the federal MIECHV guidance, the resolve also requires that the funding support both direct services and the continued investment in quality assurance, evaluation, and professional development infrastructure. Finally, it requires the DHHS to report on the plan to the Legislature and grants the Department the authority to propose legislation related to home visiting programs, a move unusual even in more amicable legislative sessions. RESOLUTION OF CHALLENGES Operationally, Maine is confident that the processes it already has in place with quality assurance, evaluation and administration will accommodate any extraordinary circumstances with direct service delivery. Programmatically, we are challenged by a demand to use this federal funding stream as a means of financial support for other home based programs who self-identify as home visiting programs. Unfortunately, these programs do not have a documented history of accountability, cost efficiencies, positive outcomes, and fidelity to national evidence based model as outlined in the federal guidance. We intend to resolve this issue by recognizing and naming this political and collaborative dynamic, and ensure that we continue education on the federal legislation as we continue our state systems change efforts to maximize existing resources. We believe that continuing to reiterate that it is the people, not the funding, that can change the system and we can do so through shared professional development opportunities, shared data collection, shared referral systems, so that we can increase the number of families served by all of our respective programs with no new funding. Administratively, we may encounter resistance with the approach to sustainability via analysis of Medicaid regulation. By capitalizing on the expertise of credible and nationally-known organizations (the BUILD Initiative and the Urban Institute), the angst that accompanies bold change should be mitigated. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

35 EVALUATION AND TECHNICAL SUPPORT CAPACITY The University of Southern Maine (USM) will take the lead on Maine s MIECHV Expansion Grant Evaluation. The project will be staffed by a team of experienced evaluators, and funded by MIECHV Expansion funds ($334,867 in Year 1, additional in Years 2-4). Current experience, skills, and knowledge of the evaluation team The lead evaluator, Erika Lichter, ScD, is an Assistant Research Professor in the Department of Applied Medical Sciences (AMS) at USM and has been the lead MCH Epidemiologist at the Maine CDC since She holds a doctorate degree in Maternal and Child Health from the Harvard School of Public Health, a master s degree in Public Health from Harvard, and a master s degree in Developmental Psychology from the University of Arizona. She is currently the lead evaluator on Maine s Kids Oral Health Partnership Project and Maine WIC s Special Project Grant, and was co-evaluator of the Maine Youth Suicide Prevention Program s schoolbased suicide prevention project from She has experience using mixed methods for data collection and analysis, and has conducted participatory evaluations. She has extensive experience conducting epidemiologic studies and is skilled in quantitative data analysis, including multi-level modeling. Brenda Joly, PhD will be the co-evaluator on this project. Dr. Joly will provide expertise and scientific direction on the design and incorporation of continuous quality improvement components in the evaluation plan and qualitative instrument design. Dr. Joly is an Assistant Research Professor in the Muskie School at USM. Her area of expertise is public health evaluation and research. She has led and managed numerous evaluation efforts, including national multi-state evaluations (e.g., Multi-State Learning Collaborative). The evaluation team will also include Denise Yob, MPH and Cindy Mervis, MPH, MCH epidemiologists with extensive experience using administrative databases, will help with the implementation and analysis of data for benchmark measures, and assist with the data linkage projects. Prashant Mittel, MS, will provide statistical support to the evaluation. He is experienced in advanced statistical techniques including regression analysis, mixed modeling including generalized and hierarchical modeling, survey sampling, and weighting techniques. Diane Friese, MLIS will assist with the collection and analysis of qualitative data. She has directed qualitative evaluation activities and been an active participant on several large project evaluation teams. Finn Teach, MPP will provide ongoing support to project staff and stakeholders. The evaluation team will be coordinated by Barbara Poirier, MS, who will oversee all project evaluation activities amongst team members, serve as interface between program implementation teams and evaluation team, assist in developing qualitative data collection instruments, and assure data collection, analysis reporting is carried out according to the work plan. She brings over 10 years of experience in managing public health initiatives and possesses strong qualitative research skills. Organizational experience and capability to coordinate and support the evaluation USM s Department of AMS has a long and successful track record of applied research and public health epidemiology. USM Muskie s Cutler Institute for Health and Social Policy is home to 202 research staff and faculty responsible for over $28 million in annual sponsored research. The professional research and epidemiology staff in AMS and the Cutler Institute are experienced in program evaluation, quantitative and qualitative data collection, analysis and dissemination. This project will take advantage of the infrastructure that supports extramural Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

36 research at USM: protocols for assuring data integrity and security, review by the Institutional Review Board, financial management, and human resource management. EVALUATION PLAN The evaluation of Maine s MIECHV Expansion Program will focus on the implementation and outcomes of the four expansion activities in this proposal, (1) increased capacity of the Maine Families (MF) program to make Parents as Teachers (PAT) accessible to all eligible families, especially vulnerable families; (2) enhancement of PAT service delivery (i.e., Linking Initiative) to include increased frequency of visits, increased clinical supervision and training, and strengthened collaboration among service providers to better serve vulnerable families; (3) increased capacity of MF sites to report required Benchmarks; and (4) increased coordination of Maine s early childhood system. The main evaluation questions include: Implementation evaluation questions: Is MF succeeding in serving more eligible families--including families with needs related to substance abuse, mental health, and/or family violence issues, families in rural areas, and families living in tribal communities? Is fidelity to the PAT program maintained in the context of expansion? What factors (participant, agency, community) influence program implementation and fidelity? How is the proposed PAT Linking Initiative implemented across sites and what factors influence its implementation? To what degree are MF sites implementing required Benchmark data collection and reporting and what factors influence implementation? How successful was the project in establishing collaborative relationships and coordinated systems between agencies at the state and local level? What were the barriers to and facilitators of collaboration and coordination? Outcome evaluation questions: Are MF services improving the health and well-being of the population served? Does the Linking Initiative contribute to improved family outcomes when compared to historical outcomes from previous MF implementation of PAT? What factors (participant, agency, community) influence outcomes for families? Are families receiving more services in a more timely fashion as the result of increased collaboration and coordination at the state and local level? Detailed summary of key evaluation questions, measures, and data sources. Evaluation Questions Measures Data Source* Implementation evaluation: Are more eligible families being served? Is fidelity to the PAT program maintained in the context of expansion? a. Percent of eligible families residing in MF catchment areas (i.e.. are there underserved geographic regions?) b. Number and types of eligible participants served in program catchment areas c. Number of rural,/isolated families, triabl families, and vulnerable families (e.g., rural/isolated, substance abuse, mental health, family violence) served d. Number of miles traveled by home visitors to serve rural and isolated families a. Number of visits per family b. Duration of participation (i.e., # of months or years; participant retention rates) Birth certificates OSA treatment data MACWIS MF database Key informant interviews Site visits MRQ MF database Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

37 Evaluation Questions Measures Data Source* c. Alignment of visit content with PAT model Interviews with staff, d. Quality of services delivered participants and agency e. Staff retention rates directors f. Percent of MF staff trained in PAT and enhanced components Staff survey (e.g., Touchpoints) Participant survey g. Percent of staff who receive annual training Direct observation h. Number of trainings available to staff i. Staff perceptions of training availability and adequacy j. Adherence to Standards of Practice k. Provision of supervision to staff, including consultation and fidelity monitoring How is the proposed PAT program enhancement, or Linking Initiative, implemented across sites and what factors influence its implementation? How do staff and participant characteristics influence program implementation? How does community context impact who gets served, and how services are delivered? What is the data collection capacity of MF agencies to report on federal benchmarks? How successful was the project in establishing collaborative relationships and coordinated systems between agencies at the state and local level? How does community context influence collaboration? a. Available number and type of services by site b. Number of referrals and contacts made to families enrolled in program a. Number of referred families who receive services b. Number of different services used by families Staff trainings provided in substance abuse, mental health, family violence c. Staff confidence in working with high-risk families d. Number of formal agreements created between agencies a. Demographics of participants and staff who are retained and those who drop out b. Staff training, experience and caseload related to participant and staff retention and participant experiences with program c. Participant-Home Visitor relationship d. Cultural competency of staff and its relationship to participant experience and retention a. Demographics of community in relation to MF participant demographics b. Services available compared to services delivered c. Community strengths in relation to services delivered and participants served d. Services gaps a. Existence of data collection system that includes federal benchmarks b. Staff training and supervision to collect and report benchmark data (including adoption of some additional screening tools) c. Percent of families for whom federal benchmark data are complete d. Percent of HV agencies that report on federal benchmarks annually e. Quality of reported benchmark data a. Number of families referred to local agencies b. Percent of referrals that result in family receiving services from local agencies c. Levels of collaboration, before/during/after expansion d. Collaboration map e. Number of MOUs that existed prior to expansion and toward end of expansion grant a. Results of collaboration surveys and interviews by community and at the state-level Agency director interviews MF database Staff survey Documentation such as MOUs, MOAs, shared tools and processes (e.g. joint referral systems, intake forms, marketing materials) MF database MRQ data Participant interviews Staff interviews Staff surveys Census Local service inventory Interviews with local agencies and participants Participant surveys Community & agency profiles MF database Agency director interviews Direct observation Birth certificates (to examine comparability of data between sources for quality assessment) Collaboration Survey and maps Stakeholder and agency interviews Collaboration Survey and maps Community/Agency profiles Stakeholder and agency interviews Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

38 Evaluation Questions Measures Data Source* Outcome evaluation Are MF services improving the health and Improvement in the following benchmarks and associated constructs as identified in Maine s State Plan: Birth certificates MACWIS well-being of the a. Improved maternal, newborn, infant and child health MF database population served? b. Prevented/reduced child maltreatment and injuries Mainecare (Medicaid) c. Prevented/reduced domestic violence d. Improved school readiness How are participant characteristics related to their outcomes? How do participants experiences with the program relate to participant outcomes? Does community context influence outcomes of the populations served? Does the Linking Initiative contribute to improved family outcomes when compared to historical outcomes from previous MF implementation of PAT? e. Increased positive parenting practices a. Socio-demographic factors examined in relation to program outcomes a. Number of visits/duration of participation by participant outcomes b. Participant engagement in program by participant outcomes c. Participant/Home visitor relationship in relation to participant outcomes a. Participant outcome differences by region and/or specific contextual variables (e.g., rurality, availability of service, quality of service delivery) a. Improved participant outcomes compared to historical controls (see methods for additional info) MF database Participant survey MF database Participant survey Participant interview Birth certificates MACWIS MF database Community/Agency profiles OSA treatment data MACWIS Birth certificates MF data *OSA= Office of Substance Abuse; MF=Maine Families; MACWIS = Maine Automated Child Welfare Information System; MRQ=Maine Roads to Quality (staff training data) EVALUATION Methods The overall evaluation methodology will be grounded in CDC s Framework for Evaluation (CDC, 1999), which specifies steps and standards for effective program evaluation. We will utilize participatory evaluation methods, defined by Rossi, Lipsey and Freeman (2004) as an evaluation in which stakeholders are directly involved in planning, conducting, and analyzing the evaluation in collaboration with the evaluator. To accomplish this, we will partner with the MF Program to create a joint CQI/Evaluation Advisory Committee that will include MF agency directors, home visitors, MF participants, state staff, staff from collaborating programs, and evaluation staff. This committee will work with the evaluation team to identify key evaluation indicators, provide feedback on data collection instruments and administration, provide input on interpreting evaluation results, and assist in disseminating evaluation findings for program modification and planning. Since the expansion of Maine s Home Visiting model will occur statewide, the evaluation will rely primarily on longitudinal data collection of implementation and outcome indicators using a multiple data sources. The four main components of the MF evaluation plan are described below: 1. Community/Agency Contextual Assessment: For each agency, a detailed profile will be developed that includes community context data from: US census, birth certificates, linked infant-birth death files, substance abuse treatment, child welfare, Maine s Pregnancy Risk Assessment Monitoring System (PRAMS), Medicaid, hospital discharge data, and an inventory Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

39 of local community organizations. In addition, agency-level data will be compiled that will include: staff demographics, caseload numbers, and information on current collaborative efforts by the agency. The quantitative data collected for these assessments will be supplemented with qualitative data from interviews with MF staff/directors, participants, and collaborating agencies. These assessments will be used to examine community and agency level factors that influence program implementation and participant outcomes. 2. Implementation Evaluation: The purpose of the implementation evaluation is to examine how the expansion grant impacts the number and types of families receiving MF services and how fidelity to the evidence-based home visitor PAT model is maintained throughout the expansion. The implementation evaluation will also describe the factors that allow the expansion activities to succeed and those that present barriers. The methods used in assessing program implementation and fidelity will be based on indicators developed by Daro (2010) and will include: Program level characteristics (e.g., number of families who enroll in the program, changes in service model based on participant need or local context, organizational cultural competence); Direct service staff level characteristics (e.g., staff demographics, monthly caseloads, staff training experience); Participant-level information (e.g., participant demographics, referral information); and Participant program experiences (e.g., number of home visits completed with each participant, content of visits, quality of visitor-participant relationship). A full list of implementation indicators will be developed in collaboration with the CQI/Evaluation Advisory Committee. Data for these indicators will be gathered mostly through Maine s MF Data System, and supplemented by interviews and surveys. Each indicator will be measureable, ensuring that a quantitative fidelity score can be created for each agency. We will use qualitative data to improve our understanding of the strengths and challenges related to implementation. Data on many of the implementation indicators are available historically from the MF database. We will analyze data on these indicators from the five years prior to the expansion grant period and annually throughout the grant period to monitor how the expansion impacts program implementation. All implementation questions will be examined in relation to community and agency level context to evaluate how context influences who is served, types of services delivered, and service quality. 3. Outcome Evaluation: The outcome evaluation will address (1)the extent to which the MF program improves participant outcomes and (2)how the proposed Linking Initiative enhancement to PAT for vulnerable families improves participant outcomes beyond Maine s current implementation of the PAT model. Key outcome indicators will be identified in to align with federal Benchmarks and PAT program focus areas: Maternal and infant health, school readiness/promising parental practices, child maltreatment and injury, and domestic violence. In addition, we will develop indicators to measure access and utilization of services, resources and supports, and measures of effective collaboration. The methodology of the outcomes evaluation will involve four components: (a) tracking MF participant outcomes using the MF data system; (b) Comparing a cohort of MF families to families not enrolled in MF using administrative data; (c) Assessment of the PAT Linking Initiative on participant outcomes using historical controls; and (d) Appraisal of collaborations and coordination achieved through the expansion. a. Tracking MF participant outcomes using the MF data system: Key outcome indicators are collected through the MF home visitor tracking system. We will monitor these outcomes over time by examining data from the five years prior to the expansion grant through the end of the 4-year grant period. We will conduct analyses examining the relationship between participantlevel, agency-level, and community-level variables and these outcomes prior to the expansion, Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

40 midway through the expansion period, and at the end of the expansion period to determine the extent to which the program objectives have been met for the scale up. b. Evaluation cohort: Although we will track outcomes for all MF participants enrolled during the study period, we will also use the birth certificate database to link births during the first year of the evaluation period with the MF database in order to identify two cohorts of infants: those whose families participated in MF and those whose families did not participate. These two cohorts will both be linked to the Medicaid and child welfare datasets. The linked datasets will allow us to compare health and welfare outcomes between MF participants and infants with similar demographics who did not participate in the MF program. We also will be able to further subdivide the MF cohort into those infants whose families enrolled prenatally and those with postnatal enrollment, which will allow us to evaluate the impact of prenatal enrollment on perinatal risk factors and birth outcomes, as well as longer term outcomes. The purpose of these comparisons is to measure the extent to which the attainment of program objectives can be attributed to the project. c. PAT Linking Initiative: We will use the MF data system to identify historical controls, families of similar demographics who would have been enrolled in the linking program had it been available at the time of their enrollment in MF (Fink, 2008; Marungwa et al, 2007). We will compare outcomes of families who receive the PAT linking program to these historical controls to investigate the extent to which the Linking Initiative provides additional benefits. d. Collaboration and coordination: We will use quantitative collaboration measures developed for measuring community partnerships to track relationships between community agencies at baseline and at regular intervals throughout the study period. The quantitative data will be supplemented through staff, participant, and agency director qualitative interview data. 4. Benchmark Reporting: The evaluation of this program will ensure that grant-required benchmark data are collected from each agency and data are submitted annually. The proposed data linkage projects will allow for assessment of quality of the some indicators (e.g., perinatal outcomes). Benchmark data will be compiled into an annual report that will be available to MF agencies, key collaborators, and the public. Data Sources and Collection We will use surveys, administrative data, and key informant interviews to track expected outcomes. Maine Home Visitors Data System: MF maintains a comprehensive web-based data system that provides real-time access to program and participant information. The system will be enhanced through the expansion grant to capture key outcome variables and federal benchmarks. Maine Roads to Quality Data System: Maine Roads to Quality (MRQ) is a joint venture between USM and Maine s Office of Child and Family Services. MRQ maintains a database that documents educational level as well as all trainings completed by MF staff. Interviews: Interviews with participants, staff, and staff from key community and state agencies will be conducted at the beginning and end of the project. These interviews will be semistructured discussions based on questions developed by the evaluation staff and Advisory Committee. The interviews will be audiotaped (with permission), transcribed, and analyzed using qualitative data analytic methods to identify key themes. The table below summarizes the interview formats and topics by population. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

41 Summary of Evaluation Interview Data Collection Population Interview Interview topics format Participant Group Needs; perceptions of program; how well program meets needs; suggestions for improvement; factors related to retention; relationship with home visitor Staff Group Perceptions of participant needs, types of staff training requests, challenges of working with diverse populations, and strengths and challenges of HV expansion.. Information on staff perceptions of inter-agency collaboration throughout the duration of the program will also be collected and analyzed. Agency directors Individual Agency structure; characteristics of communities in which agencies are located; nature of collaboration between agencies; challenges and strengths in service delivery and collaboration across the state and within the community Key collaborators Individual Levels of collaboration with MF agencies and other local partners; perception of community and its needs; barriers and supports related to collaboration Surveys: Participant and staff surveys will be administered at baseline and at the end of the project period. The participant survey will assess participant satisfaction with interactions with their home visitor, participant staff communication, respect for participant preferences and shared decisionmaking, experiences leading to trust or distrust and experiences of discrimination. (Krysik et al, 2008; Wagner et al, 2000). The staff survey will assess confidence in implementation of the PAT program, level of knowledge in addressing key issues such as substance abuse, mental illness, and cultural competency, and perceptions of supervision. Individual responses will be tracked over time to examine change as the program expands. For a sub-sample of home visitor-participant pairs, we will administer the Working Alliance Inventory-Short Form (Horvath and Greenberg, 1994; Horvath, 1995 cited in Daro, 2010), which was used in the national home visiting cross-site evaluation. Collaboration survey: This survey will be adapted from surveys developed by Frey et al (2006) and Cross et al (2009) and will be administered to MF agency directors, state MF staff and key collaborator agency directors to gauge levels of collaboration. The survey will be administered at baseline, during Year 2, and at the end of the study to evaluate changes in collaboration. Collaboration maps will be developed based on survey responses, which will be used to assess collaboration at the local level and at the state-level. Administrative data: Administrative databases will be used to compare MF child outcomes to those not enrolled in MF. USM staff have access to electronic birth files on an annual basis through Maine s Office of Data, Research and Vital Statistics. Maine s child welfare program maintains a data system, MACWIS, to track cases of reported child abuse and maltreatment. We plan to use MaineCare (Maine s Medicaid Program) data, to compare utilization of health care utilization by MF participants and non-mf participants. In addition to these data sources, we will use substance use treatment data from Maine s Office of Substance Abuse in our community assessments and to examine the program s reach in enrolling women with substance abuse problems. Census data, hospital discharge and emergency department data, and Maine s Pregnancy Risk Assessment Monitoring System (PRAMS) data will also be used in the development of community/agency assessments. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

42 Data Collection and Analysis Methods Data Source Type of instrument used Person responsible for administration MF database Web-based participantlevel HV staff and data data collection system managers system Participant group Semi-structured interviews interview Participant survey Paper-pencil survey Given to participant at home visit by agency staff Staff survey Staff interviews Web-based quantitative survey In-person semistructured interview and quantitative measures Analytic Frequency Annual query of key indicators Analytic Method Quantitative- Repeated measures controlling for clustering within sites Evaluation staff Years 2 & 4 Qualitative- thematic coding Evaluation staff Evaluation staff Years 2 & 4 Years 2 & Year 4 Year 2 & Year 3 Collaboration survey Web-based survey Evaluation staff Years 2, 3 & 4 Quantitative MF agency director and collaborating agency director interviews In-person semistructured interview and quantitative measures Quantitative controlling for clustering Quantitative Change scores, controlling for clustering Qualitative- thematic coding and Quantitative- repeated measures Evaluation staff Year 2 & 3 Qualitative- thematic coding and Quantitative- repeated measures Analysis: This evaluation will use both qualitative and quantitative analysis to assess fidelity, collaboration, and participant and program outcomes. To analyze the qualitative data, we will code the individual interviews and identify themes across the different data sources. To ensure reliability, at least two evaluation staff members will code each interview. Atlas.ti (Scientific Software Development, 1997) will be used to help with coding and organizing the data. The qualitative data will be summarized for the program overall and stratified by agency. Quantitative data analyses will include univariate and multivariable analyses. Data on program implementation indicators (e.g., number of clients served), will be tracked monthly and trend analysis will be used to examine statistically significant changes over time. We will conduct multivariable analyses (i.e., logistic and linear regression) to examine how contextual factors, such as rurality and agency-level variables, are associated with fidelity measures. Some qualitative data will be coded and quantified to be included in these analyses. We will conduct similar analyses on participant outcomes. Outcomes will be tracked over time, and contextual and agency level variables will be examined to determine how they are associated with improved participant outcomes. Due to the clustered and multi-level nature of the data (e.g., individual level, agency level and community level variables), we will use multilevel longitudinal analysis to examine the relationship of different factors on participant outcomes over the course of the study (Fitzmaurice, Laird and Ware, 2004). Linked home visiting enrollment data and birth certificate data will be used to examine whether there are statistically significant differences in perinatal health indicators between newborns whose families participated in MF during pregnancy and those whose families did not. Similar analyses will be conducted on health care utilization using linked Medicaid/MF data. Multivariable analyses will be conducted using MF participation as an independent variable and the analyses will be controlled for potential confounders that can be found on the birth certificate or Medicaid files (e.g., parent education, geographic location). For child maltreatment, we will Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

43 use univariate analysis to examine the difference in case identification between MF families and non-mf families. Depending on the number of cases identified during the study period, we will conduct stratified analyses or use survival analysis to examine time to case identification and compare MF participants to other families with children born during the same time period. Propensity scoring methods will be used to control for differences between MF participant and non-participants groups (D Agostino, 1998). Institutional Review Board (IRB) approval IRB approval will be sought by the lead evaluator from the University of Southern Maine and the Maine CDC. Dr. Lichter has worked with USM s IRB on several other projects and is currently a member of the Maine CDC s Institutional Review Board. How Maine s work plan/implementation plan address Priority Area 7 Maine s expansion grant is focused on Priority Area 7: To reach families in rural and frontier areas. Throughout the evaluation, we will document how contextual level factors influence program implementation and outcomes. Part of this context will include examine how rural and isolated families are served by the home visiting program and how factors related to rurality (e.g., long distance travel to see families) impact effective implementation. How the proposed evaluation meets the standards of a high or moderate quality study design and is independent: Maine s project involves scaling up current activities and developing formal systems to ensure that the most vulnerable families served are connected to needed services in a coordinated manner (i.e., Linking Initiative). The core PAT model is not being changed in this project, and no program adaptations are proposed. Our approval letter from PAT developers confirms that Maine s proposed program enhancements are determined to be consistent with model fidelity standards. Therefore, the methods of the proposed evaluation do not meet the criteria of a high or moderate study design. Instead, quasi-experimental methods are employed through the use of administrative data and historical controls. Analytic methods will be used to account for control group differences and clustering of outcomes by site. The evaluators for the project are employed by the University of Southern Maine; they are not affiliated with the Maine Families Program or the State of Maine. References Centers for Disease Control and Prevention. Framework for Program Evaluation in Public Health. MMWR 1999;48(No. RR-11). Cross JE, Dickmann E, Newman-Gonchar R, Fagan JM. Using mixed-method design and network analysis to measure development of interagency collaboration. American Journal of Evaluation, 2009; 30: D Agostino RB. Propensity score methods for bias reduction in the comparison of a treatment to a nonrandomized control group, Statistics in Medicine, 1998,17: Daigneault P, Jacob S. Toward accurate measurement of participation: Rethinking the conceptualization of participatory evaluation. American Journal of Evaluation, 2009; 30: Daro D. Replicating evidence-based home visiting models: A framework for assessing fidelity. Supporting Evidence-based Home Visiting to Prevent Child Maltreatment, December 2010; Brief 3. Fink A. Practicing Research :Discovering Evidence That Matters. Los Angeles, CA: Sage Publications. Fitzmaurice GM, Laird NM, Ware JH. Applied Longitudinal Analysis. 2004; Hoboken, NJ: Wiley. Frey BB, Lohmeier JH, Lee SW, Tollefson N. Measuring collaboration among grant partners. American Journal of Evaluation, 2006; 27: Krysik J, LeCroy CW, Ashford JB. Participant perceptions of healthy families: A home visiting program to prevent child abuse and neglect. Children and Youth Services Review, 2008; 30: Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

44 Marigwa, JT, Faes C, Aerts H, Geys H, Teuns G, Van Den Poel B, Bijnens L. On the use of historical control data in pre-clinical safety studies. Journal of Biopharmaceutical Statistics, 2007; 17: Rossi PH, Lipsey MW, Freeman HE. Evaluation: A Systematic Approach. Thousand Oaks, CA: Sage Publications. Wagner M, Spiker D, Gerlach-Downie S, Hernandez F. Parental engagement in home visiting programs-findings from the Parents as Teachers multisite evaluation policyweb.sri.com/cehs/publications/pat_engage1.pdf accessed 6/15/11 ORGANIZATIONAL INFORMATION Mission, Structure, and Philosophy in Action The Maine DHHS Early Childhood Initiative is focused on engaging public and private support to assure coordinated systems of care that promote optimal well-being of families and quality, accessible programs that are coordinated, flexible, and family centered so that strong, selfsufficient families live and work in stable, safe and supportive Maine communities that value their children. As the locus of the Early Childhood Comprehensive Systems (ECCS) Grant, the Early Childhood Initiative (ECI) has already addressed the kind of governance and inter-agency challenges demanded of this expansion project: it has a Memorandum of Understanding between the Maine CDC and the OCFS (available upon request) that specifies processes for financial management and reporting, contract management, communication, and a focus on primary prevention and early intervention activities. These are actively demonstrated through the success of the Maine Children s Growth Council, Project LAUNCH, and the Maine Families program, as well as the successful public private partnership with the Maine Children s Trust Fund through alignment of private, state, and federal funds for the provision of evidence-based parent education and child maltreatment activities. Maine s ability to fulfill the needs and requirements of the MIECHV Expansion The ECI Director has helped guide the ECCS plan implementation such that Children s Growth Council appointed members, community partners, funders and stakeholders own and drive its work. Application of this philosophical approach helps ensure sustainability and grounds the efforts in functionality, not personality, which endures even dramatic political and administrative transitions at the state level. The pieces of the MIECHV Expansion puzzle are not only there, but are already falling into place to realize the vision of a comprehensive home visiting continuum of services: The ECI has an existing expectation for performance based contracting and accountability. It has shown a commitment to employ processes that ensure stakeholder participation because it is necessary not only to inform realistic changes in practice, but also to sustain these very changes. It has the statutory requirement to provide regular reports to the Legislature on home visiting and the internal requirement to report no less than quarterly to the DHHS Commissioner s Grants Review Committee. Above all, it has engaged concurrence and commitment from a broad array of key public and private partners for involvement in and implementation of the state plan for home visiting, the scope of which is illustrated with the Project Organization Chart in Attachment 5. Maine s history of significant progress towards implementing a high-quality home visiting program in a comprehensive, high-quality early childhood system. MIECHV Expansion funds will augment Maine s work of building a statewide early childhood system that is grounded in home visiting as a primary prevention public health strategy. Maine is Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

45 historically committed to implementation of home visiting as part of a comprehensive early childhood system one that emphasizes evidence-based practice, quality assurance, and optimal coordination of services. Indeed, the first iteration of the state s present early childhood advisory council, the Maine Children s Growth Council, was from a legislative Task Force convened to study home visiting as a means to improve child outcomes nearly 15 years ago. Home visiting has remained as a core component of the early childhood state plan since its inception. Maine s broader early childhood systems efforts through the MCH Early Childhood Comprehensive Systems (ECCS) grant has included quality home visiting The ECCS Director, Sheryl Peavey, is also the state home visiting program administrator, and the MIECHV project director. Ms. Peavey recognized that the federal legislation for home visiting was grounded in a systems approach, and has guided the work accordingly. She has sought public input by bringing the MIECHV Needs Assessment to the state early childhood advisory council (the Maine Children s Growth Council); ensured that the Maine Children s Growth Council website included a specific page dedicated to the home visiting initiative and its documentation; and leveraged an existing Early Head Start Systems technical assistance grant with Zero to Three to bring national expertise and tools to the process of developing the home visiting state plan. Zero to Three coordinated and facilitated two statewide stakeholder meetings aimed at building a more coordinated state system. These meetings included Maine Families home visiting program managers, Early Head Start and Head Start Directors, child protective caseworkers and leadership, state agency substance abuse representatives and community providers, advocates and others. Details about the stakeholder meetings and the state proposals and state plan are available at the Maine Children s Growth Council website: Attachment 6 provides additional detail about Maine s experience and progress in both home visiting and the broader early childhood systems efforts. How Maine has already addressed the priority area at a regional or state level and has made significant improvements in other areas of early childhood systems. Operationally, Maine s proposed program expansion will build on an already existing network of statewide home visiting services, the Maine Families program, reaching more than 2,500 families annually in every county in Maine. Since 2008, all Maine Families sites have been implementing Parents as Teachers and the Touchpoints approach of reflective practice and reflective supervision. Knowing that rural states can be challenged with travel, travel time, and isolation, we invested in in-state capacity for training for national models, and a single webbased data collection system. Fostering a governance culture that has embraced and included evaluation and continuous quality improvement, the state administrator has ensured that home visiting has a history of performance based contracting, data driven decision making, and proven improvements in child and family outcomes. The proposed enhanced program will be integrated into this already existing system and will build on our highly trained, highly skilled Maine Families workforce. More importantly, the four major components of this expansion proposal are purposefully crafted from or woven into the existing activities of the state to have a comprehensive early childhood system: increasing direct service capacity for greater access to quality early childhood services, investments in professional development and evaluation provide greater opportunity to improve the early childhood workforce, driving changes in state Medicaid regulations to maximize state and local resources, and offering consistent messaging about the connection between early childhood programs like home visiting and the state s economic and social prosperity. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

46 Qualifications and Experience of Project Personnel Project Director: Sheryl Peavey, Director of the Early Childhood Initiative and appointed Public Health-Child Welfare Liaison, has overall responsibility for state level management and supervision of the Maine Families and MIECHV Programs. Ms Peavey has served as the project director or co-principal investigator for multiple federal initiatives, including Project LAUNCH (a Substance Abuse and Mental Health Services Administration grant) and the Child Care Research Capacity Partnership (a project of the Office of Policy, Research, and Evaluation of the US DHHS Administration for Children and Families). She is a trained Future Search Facilitator, has a background in evaluation and home visiting administration, functions as an interagency liaison, and has successfully led the Early Childhood Comprehensive Systems work for seven years in Maine State Government. State Coordinator: Consultant Pam LaHaye is well qualified to support the success of this project, having served as the State Coordinator and QA/TA Specialist since 2008 and worked in the home visiting field since She has been a home visitor, program manager, model developer and trainer as well as Coordinator and has demonstrated her skill for state level coordination and provision of training/technical assistance, quality assurance and continuous quality improvement efforts, and serving as liaison with PAT program developers. Most importantly, she has the respect and trust of the community providers, as noted in one June 2011 correspondence with the State Administrator: [Pam} has been instrumental in pulling us together and seeing each other's strengths and challenges as both being critical pieces to learn from. Direct Services: It is clear that the experience and expertise of the direct service providers is critical in this relationship-based work; which is why the state will contract with existing Maine Families provider agencies for expanded service delivery using an already-established performance-based contracting system. All of these agencies have been providing home visiting services to new families for at least eleven years, and some for many more years than that. Contracts are required to comply with policies and standards as outlined in the Maine Families Standards of Practice, which meet or exceed the criteria of the PAT model. Rigorous quality assurance has resulted in contracts being terminated with providers unable to produce successful outcomes and comply with the Standards of Practice. This network of providers has blossomed because the state rewarded its authentic collaboration; rather than compete for funds, these providers use their energy to improve their services by supporting each other. They shed their individual identities to become a cohesive brand recognized across the state and found unity of purpose and practice in this transformation. Clinical Consultants: Three clinical Consultants will be hired by Maine Children s Trust to assist home visitors in better serving families with substance abuse, mental health, co-occurring, and family violence issues. The Clinical Consultant positions require a Master s degree in social work or counseling, current licensure, experience in providing direct clinical services to overburdened families with infants/young children, infant mental health training, experience with home visiting programming, and experience and training in reflective practice and reflective supervision, with PAT and Touchpoints training and experience preferred. Collaboration Specialist: The state will contract with a Collaboration Specialist to facilitate statewide systems coordination and provide technical assistance to local Linking efforts. A potential candidate is Erica Schmitz, Public Health Program Manager at Medical Care Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

47 Development. Over the past six months, Ms. Schmitz has assisted the Early Childhood Initiative to further the MIECHV planning process by conducting stakeholder interviews, convening work groups, and drafting recommendations. Ms. Schmitz brings more than 12 years of experience in community organizing and coalition-building within the public health arena, and more than 5 years of experience in provision of training and technical assistance for state agencies. She is experienced in bridging multiple demands from state, federal funders, and community stakeholders. Evaluation Team: With a team from the University of Southern Maine composed of doctorate and master s level epidemiologists and evaluators with more than half a century of collective experience, Maine is confident that the team measuring project success will do so with objectivity and unparalleled attention to detail. Maine s capacity to bring the MIECHV Expansion Project to scale As described in the sections above, Maine has a high level of capacity and readiness to implement the proposed expansion. This includes ualified personnel and management capacity with an unprecedented level of oversight from the executive and legislative branches of state government. We have a proven history of intentional inclusion of stakeholders, collaborative relationships, and buy-in from communities. As noted earlier, there is more than a long-standing connection to the Maine Children s Growth Council, which has the charge and authority to address policy issues that improve or impede state level early childhood systems. Most importantly, to bring this work to scale requires a solid network of statewide home visiting services, which we have in the Maine Families program. Since 2008, all Maine Families sites have been consistently implementing the evidence based model, Parents as Teachers and using the Touchpoints approach of reflective practice and reflective supervision. We have infrastructure in place that is presently being aligned and refined using the federal MIECHV legislation and guidelines. We have planned for sustainability from the onset, and rather than listing activities with learning curves and start-up time/costs, we are building on existing social marketing efforts of the Children s Growth Council, leveraging technical assistance for Medicaid financing options, continuing collaboration workgroups with specific systems components to address, and bolstering evaluation in an environment already used to close scrutiny and data driven program improvements. These strategies have helped to ensure model fidelity, consistency, and coordination of home visiting services statewide and will now assist the state in bringing the project to scale statewide within the proposed timeline. Maine s proposal and capacity to reach an appropriate number of individuals As described above, Maine s proposed expansion work plan was developed in close consultation with Maine Families program managers, who were asked to identify realistically how many staff they could add without compromising quality and fidelity to the PAT model. The resulting numbers, which include a gradual year-by-year program expansion, are based on careful consideration by local providers regarding their own capacity for growth. Year 1: Up to 25 new direct service positions and 5 supervisory positions will be added to serve an estimated 700 families per year. Allowing 6 months for hiring, training, and orientation, about half (350 new families) would be served by the end of the first year. Year 2: Up to 15 new positions will be added to serve an estimated 400 families per year. Allowing 6 months for hiring, training, and orientation, about half (200 new families) would Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

48 be served by the end of the second year. ( =900 families served by MIECHV Expansion in Year 2.) Years 3 & 4: In Year 3, program eligibility will be expanded to include families with children ages 3-5. Up to 15 new positions will be added each year, to serve an estimated 400 families per year. Allowing 6 months for hiring, training, and orientation, about half (200) would be served by the end of the first year. ( =1300 families served by MIECHV Expansion in Year =1700 families served by MIECHV Expansion in Year 4.) Maine s Record of Accomplishment As noted throughout this proposal, Maine has a proven record of establishing evidence based home visiting programs that are intentionally inclusive of partners, maximize limited resources, garner powerful public support (copies of written testimony and op-eds generated during the recent legislative session by T. Berry Brazelton, PEW Trusts, state law enforcement, business leaders, medical providers and parents are available upon request), cemented in state statute, and accountable for outcomes. More information about our record of accomplishments is included under Attachment 6: Summary Progress Report. Maine s provision of culturally and linguistically competent and health literate services Home visitors are trained to use the PAT Foundational Curriculum in culturally sensitive ways to deliver services that emphasize a) Parent-child interaction; b) Development-centered parenting; and c) Family well-being. Further training in cultural competency is embedded in Touchpoints and Maine s Core Orientation trainings. The guiding philosophy underlying all work with families is derived from the Touchpoints approach. Important elements of this relationship-based model include recognition of what each person brings to the interaction; awareness of opportunities to support mastery; awareness of the child s behavior and cues; and ability to focus on the caregiver-child relationship. Cultural competence is critical to developing such relationships between home visitor and family. Maine Families home visitors are trained to engage in genuine conversation and connection with families. This requires a commitment to understanding and appreciation of the history and traditions of diverse cultures as essential in serving families. The partnership with the tribal nations to lend their perspective and experiences, as noted in their letter of support, will be crucial to ensuring respectful and welcomed delivery of home visiting services to our expanded population. In some cases, language is also an important consideration. In Northern Maine, which has a significant French speaking population, several bilingual home visitors were hired. In another county with a relatively new Somali population, the home visiting site has worked with other area providers to creatively serve these families. Feedback from families is promising. As mentioned above, each year Maine Families participants have the opportunity to respond to an anonymous survey about their experiences in the program. In the 2010 survey, 99 percent of the responding families reported their home visitor understood their needs and treated them very well; and nearly 100 percent indicated that their home visitor was respectful of their culture or background. How the unique needs of focus populations/communities served are assessed and improved Maine Families home visitors are trained to use a responsive assessment process so that their visits are tailored to each family s needs. The areas of focus for each visit to a family s home are Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

49 based on the PAT and Touchpoints curricula and are then adapted to the unique needs and interests of the family. Home visitors also perform regular developmental screenings using the Ages and Stages Questionnaire to assist the parent in understanding his or her child s development, and to assess for possible developmental delays or the need for intervention. Home visitors help families recognize their strengths and set goals using the resources available to them. Home visitors are trained to identify where and how the parent-child relationship is developing and how best to encourage that connection. Home visitors must be responsive to what the family will present to them and adapt to their needs, whether it is a better understanding their child s stages of development, recognizing parental depression, identifying patterns of substance abuse, or securing basic needs such as food or clothing. Each program uses a Family Service/Family Goals Plan to shape the content of interactions between a family and its home visitor; programs also track a family s outstanding needs as well as its accomplishments. Data from each home visit is logged in Maine s web-based case management system, used by all Maine Families home visitors and administrators. This data is used to review progress of individual families, as well as monitor community-level outcomes for purposes of continuous quality improvement. In addition, participating families are surveyed on an annual basis, giving them the opportunity to voice opinion about services offered and supports that were put in place as result of involvement with the home visiting program. This survey is anonymous and asks families about their level of satisfaction with the program. The Maine Families data and its priorities have been an integral part of the state s Maternal and Child Health Block grant application, and every year state level program managers from partners in Immunization, Injury Prevention, WIC, and Public Health Nursing review progress and discuss strategies to address any population-based concerns that emerge from the various public health surveillance methods. The organizational capacity of partners involved in project implementation Successful implementation of the expansion project is contingent upon the ability of all partners at the table to be engaged, stay engaged and to adapt to changes in policy and practices as a result of our efforts. Direct services are provided by agencies that have demonstrated experience and capacity in implementing the program Maine s youngest program delivery site is 11 years old. Seventy-nine full time equivalent staff members (including administrative and support staff) work for Maine Families statewide. Collaboration activities are being funded by this expansion grant, so participation by partners will not generate a financial or performance burden. Evaluation activities will be conducted by the University with the resources in place to support a project of this complexity. Finally, sustainability is being addressed with national, reputable partners, executive and legislative oversight, and the state early childhood advisory council using media resources that can be easily adapted for home visiting marketing. The State s Commitment to Home Visiting The drama of this recent legislative session and its budget debate illustrates the resiliency of home visiting to survive intense public scrutiny as well as the state s continued commitment to home visiting. This commitment is assured by more than written promises, it is evidenced by exceptional collaboration, statutory obligation and administrative wisdom. Specifically: The Joint Standing Committee on Appropriations and Financial Affairs presented a unanimous bipartisan recommendation to fully restore funding for Maine Families, despite a looming deficit that will continue to challenge state coffers. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

50 The Commissioner of Maine s DHHS has reiterated publicly the administration s intent to stop the costly spending on serving families in crisis and to instead put the funding into proven, accountable programs that prevent abuse and neglect in the first place. The Legislature, in its final budget discussions this June, deliberately chose to diversify the funding streams for home visiting to ensure greater stability with state general funds than the special revenues of the tobacco settlement monies which are subject to market variances. This prophetic move suggests the intent to avoid cuts to the home visiting program in the future. A portion of the restored funding for Maine Families came from child welfare funds, which was a clear statement about investing in strategies to keep children out of child welfare. Another portion of the restored funding came from general funds used as match for the State Child Care Development Fund, recognizing the symbiosis of the home visiting state plan goals with the objectives of the child care plans as co-components of an early childhood system. The language in the state budget specifically appropriates funds for the home visiting program pursuant to the Maine Revised Statutes, Title 22, section 262, that has demonstrated experience meeting state-established home visiting standards of practice for evidence based services delivery to intentionally cement the state s vision of aligning its home visiting efforts with those at the federal level. The Maine Children s Growth Council, working with the business and philanthropy communities as part of the ECCS plan, has committed to ensuring that home visiting is a funding priority option for the soon-to-be incorporated business-ceo-led Maine Early Learning Investment Group, which is being created as a means of generating private funds to help support the programmatic goals of the ECCS plan, Invest Early in Maine. The Maine Children s Growth Council has already begun discussions on ways to extend existing tax credits for business investments in child care to include more broadly, all early childhood programs, including home visiting. State officials have agreed to participate in the technical assistance offered by the BUILD Initiative and the Urban Institute to address how state and local funds could better leverage Medicaid dollars in compliance with federal guidelines and the intent of EPSDT. The Governor signed into law a legislative resolve that will ensure a strong start for Maine s infants and toddlers by extending the reach of high-quality home visitation. The Resolve requires the Maine DHHS to develop a comprehensive plan for home visiting that addresses sustainability through diverse funding streams that leverage both cash and in-kind private match wherever possible. Reflecting the federal MIECHV guidance, the resolve also requires that the funding support both direct services and the continued investment in quality assurance, evaluation, and professional development infrastructure. Finally, it requires the DHHS to report on the plan to the Legislature and grants the Department the authority to propose legislation related to home visiting programs, a move unusual even in more amicable legislative sessions. Stronger than any proposal promise, Maine s actions demonstrate its commitment to evidence based home visiting as a valued, integral part of its early childhood system. These actions will nurture and sustain the Maine Maternal, Infant, and Early Childhood Home Visiting Expansion project and foster the well-being of Maine s families and the communities in which they live. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

51 Attachment 1: Maine LOGIC MODEL FOR MIECHV EXPANSION (*Expansion-specific text is in italics) GAPS/NEEDS INPUTS ACTIVITIES/OUTPUTS SHORT TERM OBJECTIVES Many eligible families are not being reached (including those with needs related to substance abuse, mental health, cooccurring disorders, and/or family violence, those in rural areas, and those living in tribal communities). Many participants need enhanced services linking them to additional supports. Maine Families sites statewide are not yet prepared to collect and report according to federal Benchmark requirements. Maine needs increased state-level systems collaboration to build a coordinated continuum of early childhood services with home visiting as a sustainable and integral component of that system. MIECHV and State Funds MIECHV Expansion funds History and success in using PAT model Experience and capacity of program sites PAT and Touchpoints trained staff & supervisors in place statewide QA/TA Specialist to ensure fidelity to PAT model Lessons learned from Linking pilot sites Statewide data tracking system Collaborative partners at state and local level New legislation supporting state ongoing HV efforts (LD 1504) Increase number of home visiting staff; Increase number of trainings for staff; Increase travel budgets; Engage community agencies to increase referrals to home visiting program; Engage tribes to explore expansion of programming to reach families on reservations. Implement PAT enhancement ( Linking Initiative): Increase frequency of visits for families that need them; Increase clinical support for staff; Provide staff trainings on topics of substance abuse, mental illness, child maltreatment and domestic violence, and cultural competency; Increase collaboration ( linking ) among community providers. Provide technical assistance to support local linking efforts. Enhance data system; Train staff to collect and report additional data; Increase number of sites using data system for tracking. Facilitate statewide workgroup meetings to develop identify areas for change, develop shared tools and processes, and promote public and political buy-in. More eligible families served. Increase in participants identified with SA, MI, COD, or FV. Increased enrollment and participation of families living in rural areas and families living on reservations. Maintained PAT program fidelity. Maintained high retention rates for participants. Maintained high rates of participant satisfaction with the program. Maintained high retention rates for staff. Increased staff competency and comfort in addressing issues facing vulnerable families. Increased screening and referrals to needed services. Increased collaboration, formalized agreements, and shared tools/systems among local agencies to better serve vulnerable families. Data collection system enhanced to meet federal requirements. Formalized agreements among state agencies, e.g. program roles within continuum of services, staff competency standards and training plans, and consistent use of data to inform policy and services. MEDIUM TERM OBJECTIVES Increased participant knowledge and understanding of maternal and infant health, safety and parenting Increase number of vulnerable families who receive needed services (e.g. services for SA, MI, COD, FV) Benchmarks data routinely submitted to federal government and used for program evaluation Measurable progress in the MIECHV Benchmark: Improved Coordination and Referrals for Community Resources/Supports Documented agreements between state agencies to provide a continuum of support to families Public and political will for sustained funding of home visiting programs and infrastructure LONG TERM OBJECTIVES Measurable progress in the MIECHV Benchmarks and associated constructs: Improved maternal, infant and child health Reduced child maltreatment and injuries Improved school readiness and achievement/ Positive parenting practices Reduced/ prevented domestic violence Sustainable and accountable evidence based home visiting program statewide Maine MIECHV Expansion Project: Attachment 1 HRSA

52 Attachment 2: Maine MIECHV Job Descriptions for Key Personnel Director, Early Childhood Initiative (Office of Child and Family Services, Early Childhood Division, Maine Department of Health and Human Services) Statewide Coordinator and TA/QA Specialist for Maine Families (Maine Children s Trust) Fetal Alcohol Spectrum Disorder (FASD) Coordinator to be hired by the Office of Substance Abuse **************************************** Position Description: Director, Maine Early Childhood Initiative, Office of Child and Family Services, Maine DHHS This position is responsible for coordinating the development and implementation of a plan for a comprehensive and family-centered system of services throughout Maine government for young children (birth through 8 years of age) and their families. The position will facilitate, staff, and lead several task forces and state level committees, including the Maine Children s Growth Council, to guide the development and implementation of the Early Childhood Comprehensive Systems (ECCS) plan. The position is responsible for development and monitoring of ECCS goals, objectives, and strategies; assuring short and long term planning, implementation, and evaluation of ECCS activities; seeking project funding; management of ECCS grant budget; and management of grants and contracts for the statewide home visiting program and the Child Abuse and Neglect Prevention Councils. This position is assigned by the Commissioner, Maine Department of Health and Human Services upon award of the federal grants. Duties and Scope of Responsibilities Convene and staff Maine Children s Growth Council to coordinate activities, form strategic linkages, and develop and facilitate policies/systems supportive of a family-centered and culturally competent approach to Early Childhood Services. Work with Maine Children s Growth Council to identify changes needed in existing systems of services and connect with new initiatives related to the Early Childhood population. Ensure that Home Visiting Services represent the public health approach to optimal child development and the prevention of child maltreatment; Oversee the HV program and ensure quality assurance, technical assistance, training and evaluation are coordinated and support quality service delivery. Keep current with literature and activities affecting services for the Early Childhood population including legislation, policies, and regulations. Monitor Early Childhood trends and initiatives to identify and strategically address gaps/needs (such as school readiness, child health, etc.). **************************************** Position Description: Maine Families Statewide Coordinator and TA/QA Specialist Maine Children s Trust Fund (Consulting Contract) The consultant, Pam LaHaye, CFLE, coordinates trainings and quality assurance activities for the Maine Families Home Visiting Program (MF). The consultant provides recommendations regarding training and quality assurance practices to Sheryl Peavey, Early Childhood Initiative Director. The consultant provides technical assistance, along with site visits and reviews, to Maine MIECHV Expansion Project HRSA : Attachment 2 1

53 Maine Families Home Visiting Program grantees. Coordination among sites and quality assurance related to practice and data collection will be the focus of monthly meetings with the grantees. As Coordinator, the consultant assures that training activities required by the MFHV training plan will be offered and documented with the Maine Roads to Quality (MRTQ) Registry and will be responsible for certifying that all staff meet training requirements. Duties and Scope of Responsibilities: Implement a comprehensive training plan for home visitors, coordinate all training activities and provide coordination and support to all MF trainers Develop a home visiting education/training lattice for home visiting staff, review MRTQ transcripts of all MF home visiting staff annually and issue certification when staff have met all requirements. Work with the Home Visiting Evaluation agreement provider to develop and produce reports and implementation of a web-based data system Work with home visiting groups and coalitions such as the Home Visiting Coalition, Infant-Toddler Initiative, the Evaluation Advisory Group, the Maine Infant Mental Health Association and the Program Managers' Group to coordinate project goals Prepare site reports regarding provider implementation of the Home Visiting Standards Provide technical assistance to home visiting providers Serve as liaison to Parents As Teachers and support the home visiting sites in implementing the Parents as Teachers curriculum with fidelity Coordinate goals and activities of the MFHV Program with those of programs within the Maine CDC related to overlapping populations Provide support, technical assistance and assistance with special projects related to home visiting to Sheryl Peavey, Director, Maine Early Childhood Initiative, as needed. **************************************** Position Description: Fetal Alcohol Spectrum Disorder (FASD) Coordinator to be hired by the Office of Substance Abuse The FASD Coordinator is a full time position that will be contracted through the Maine Association of Substance Abuse Professionals (MASAP) and housed at the Maine Office of Substance Abuse (OSA) in Augusta, Maine. The FASD coordinator will be responsible for the development and implementation of a strategic plan for FASD Prevention, Intervention, and Treatment services as part of multiple efforts to support young children and their families affected by substance abuse. The coordinator will research and expand upon the work that was done by OSA in 2005 regarding FASD prevention and will work with OSA, the Maine MIECHV project and other statewide stakeholders in determining current needs for FASD services in Maine. Specific job duties include but are not limited to, collaboration with OSA and MIECHV on the development of a FASD strategic plan and Task Force, facilitating collaborative meetings in conjunction with the MIECHV project, completion of a FASD needs assessment, and overseeing the implementation of the FASD strategic plan. In 2004, Maine received a 2 year grant through SAMSHA that established a FASD coordinator; one key strategy from that grant included home visiting case management services to women of child-bearing age and their families with education, linkages to community resources, and support in an attempt to reduce or eliminate FASD at risk behaviors and reduce the number of FASD births. This project would re-establish the FASD coordinator and model the successful work that has been done with home visiting. Maine MIECHV Expansion Project HRSA : Attachment 2 2

54 Attachment 3: Maine MIECHV Bio Sketches of Key Personnel (Peavey, LaHaye) SHERYL PEAVEY, 75 Winding Hill Rd., S. China, ME 04358, RECENT WORK EXPERIENCE 2004-Present Maine Department of Health and Human Services (DHHS), Augusta, ME Director, Early Childhood Systems Initiative Lead/coordinate the implementation of comprehensive and family-centered system of services plan throughout the Maine DHHS and other Executive Branch departments of Maine government. Coordinate/staff Maine Children s Growth Council Advocate for Maternal and Child Health populations through presentations, participation/leadership on committees/organizations, written materials, and individual contracts. Share information regarding state Early Childhood activities. Inform and engage key stakeholders about the indicators, goals and objectives of the Early Childhood Comprehensive Systems (ECCS) state plan. Seek and support funding for existing/new initiatives that enhance the Maine ECCS work. Project Director, Early Childhood Comprehensive Systems Grant. Maternal and Child Health Bureau, Health Resources and Services Administration, US DHHS, Grant No.H25MC00266 (2004-present). Principal Investigator, First Time Motherhood/New Family Initiative. Maternal and Child Health Bureau, Health Resources and Services Administration, US DHHS, Grant No. H5MMC10868 ( ) Co-Principal Investigator, Child Care Research Capacity Project. Office of Planning, Research, and Evaluation (OPRE), Administration for Children and Families, US DHHS, Grant No. 90YE0105 (2009-present) Project Director, Maternal, Infant, and Early Childhood Home Visiting. Maternal and Child Health Bureau, HRSA, US DHHS, Grant No. X02MC19424 (2010-present) Project Coordinator, Early Childhood State Advisory Council. Administration for Children and Families, US DHHS. ARRA Award No. 90SC (2010-Present) State Administrator, Maine Families Home Visiting Program (2007-present) State Administrator, Maine Child Abuse and Neglect Prevention Councils (2008-present). Public Health Child Welfare Liaison (Maine DHHS) Co-Chair, Abusive Head Trauma Workgroup and Safe Sleep Coalition (Public-Private Coalitions) Co-Chair, Home Visiting Coalition (Public-Private Coalition) Member, LAUNCH State Advisory Partnership (Public-Private Coalition) Co-Chair, Strengthening Maine Families (Maine DHHS-Maine Children s Trust Partnership) Hornby Zeller Associates, Inc., Portland, ME Policy Analyst/Evaluator Manage evaluation project for Maine s Universal Home Visiting programs for the Maine Center for Disease Control and Prevention. Provide training and technical support for performance contracting measurement and Home Visiting Tracking System development. Conduct literature reviews, data collection, data analysis and evaluation feedback. Conduct site visits statewide with case management audits. Additional projects include: ONE ME Evaluation and Technical Assistance, Maine BDS, Office of Substance Abuse; Child and Family Services Review Analysis, Pennsylvania Office of Children, Youth & Families; Child Welfare Case Record Review Instruments Development, New Jersey DHS; United Cerebral Palsy of Maine Facilitation, United Cerebral Palsy of Maine; Dual Diagnosis (Co-Occuring Disorders) Evaluation, Maine BDS; Maine MIECHV Expansion Project HRSA : Attachment 3 1

55 ARAMARK Work/Life Partnerships, Golden, CO National Manager, Client Services Generate new business and networking opportunities in national and local forums for employer-sponsored child care solutions. Maintain corporate proficiency in Federal procurement and Department of Defense child care regulations. With CFO and other senior management, develop proforma budgets for assumption of management and new business analysis for center- and community-based child care. Write/produce proposal responses and represent corporation at formal bid presentations. Provide ongoing operations support and client services for new business. Maintain ongoing proficiency in early childhood development and quality standards of child care, including NAEYC and Reggio Emilia approaches. EDUCATION Brandeis University, Waltham, MA B.A., Cum Laude with High Honors, German Language and Literature, 1990 University of Denver, Daniels College, Denver, CO Master of Science in Education Management, Candidate HONORS/PROFESSIONAL APPOINTMENTS 2010 Steering Committee Member, Child Care Policy Research Consortium (OPRE) Secretary, Founding Board of Directors, Central Maine Youth Football and Cheering League (non-profit corporation), China, ME 2009 Elected District 4 Representative, Town of China, Budget Committee, China, ME Board Member, Maine Association for Infant Mental Health, Augusta, ME 2007 State Agency Partner for Child Abuse and Neglect Prevention, Maine Children s Trust Award President, Board of Directors, Yarmouth Day Care, Yarmouth, ME 2002 Parent Spokesperson, Colorado Children s Campaign/Educare Colorado, Denver, CO 2001 Excellence in Sales Award, ARAMARK Work/Life Partnerships % of Plan Achievement Award, ARAMARK Work/Life Partnerships 1998 Employee of the Year Award, ARAMARK Work/Life Partnerships Elected Representative, Wilmot Council, Wilmot Elementary School, Evergreen, CO SELECTED PUBLICATIONS Forstadt, L. and Peavey, S., Guest Editors. Maine Policy Review: Early Childhood Special Edition. Orono, ME: Margaret Chase Smith Policy Center at the University of Maine, 2010 Forstadt, L. and Peavey, S. Introduction to Early Childhood Special Edition, Maine Policy Review: Vol 18, No. 1. Orono, ME: Margaret Chase Smith Policy Center at the University of Maine, Sterling, L.; Peavey, S., and Burke, M. Educare: A Catalyst for Change. Maine Policy Review. Vol. 19, No. 1. Orono, ME: Margaret Chase Smith Policy Center at the University of Maine, Overcash, D. and Peavey, S. Report of Priority Recommendations for Early Childhood Investments in Maine. Augusta, ME: Department of Health and Human Services, Morrison, T. and Peavey, S. Creating Family Centered Practice in Maine: A Future Search for Child and Family Services. Augusta, ME: DHHS and Muskie School of Public Service, Peavey, S. Invest Early in Maine: State Plan for Humane Early Childhood Systems. Augusta, ME: DHHS, 2006, 2007 & Peavey, S. The Economics of Healthy Maine Children (Issue Brief for the Maine Governor s Economic Summit on Early Childhood). Augusta, ME: DHHS, Peavey, S. The Economics of Maine Early Care and Education (Issue Brief for the Maine Governor s Economic Summit on Early Childhood). Augusta, ME: DHHS, Joint Authorship. One ME Stand United for Prevention, Guide to Assessing Needs and Resources and Selecting Science Based Programs. Prepared for ME Office of Substance Abuse. Augusta, ME Maine MIECHV Expansion Project HRSA : Attachment 3 2

56 Pamela LaHaye, CFLE 96 Weymouth Road Morrill, Maine (207) EDUCATION Bachelor of Science 1976 University of Maine Child Development and Family Services WORK HISTORY Coordinator: Maine Families Home Visiting Program Contracted Consultant 2008-present Provide technical assistance to all Maine Families sites; coordinate system training activities and provide coordination and support to all MF trainers, serve as liaison with Parents As Teachers; conduct quality assurance activities to assure consistency and fidelity to Maine Families Standards of Practice and national model; represent Maine Families on multiple statewide groups working to support programming for families and young children; provide assistance with special projects related to home visiting.. State Coordinator: Parents Are Teachers Too University of Maine Cooperative Extension Led expansion of Parents Are Teachers Too model to six additional counties; developed and delivered training curriculum to all new home visitors in these counties; assisted sites with start up and provided ongoing technical assistance; served on multiple statewide groups working to support families and young children. Coordinator: Parents Are Teachers Too University of Maine Cooperative Extension Created and managed Maine s first home visiting program (serving one county), developed curriculum, authored parent handouts, created agency partnerships, supervised staff, maintained funding through successful grant-writing, provided direct service to families; served on statewide committees and coalitions to create legislation and funding streams for expansion of home visiting. Child Welfare Worker State of Maine Investigated reports of child abuse and neglect, provided supportive services; provided adoptive services; provided case management services to children in out of home placements; provided divorce custody studies. Maine MIECHV Expansion Project HRSA : Attachment 3 3

57 Attachment 4: Descriptions of Commitments/Proposed Contracts with Key Partners (in alphabetical order) Community Caring Collaborative of Washington County (Project LAUNCH grantee) Provide cost analysis of home visiting and LAUNCH (creators of the Linking Initiative concept) Offer mentoring, specialized wrap-around training and community collaboration support Coordinate the LAUNCH and MIECHV evaluations Early Childhood/PreK (Maine Department of Education) Participate in and provide technical assistance to the collaboration efforts using the successful Collaboration Coaches contracted by the Maine DOE Participate in the Continuous Quality Improvement (CQI) Advisory Team Head Start Collaboration Office (Maine DHHS) Encourage Early Head Start and Head Start participation in the statewide workgroups and local community collaboration efforts Continue discussions with the Maine Touchpoints Coordinator to assess readiness to participate in multi-disciplinary community level training Hornby Zeller Associates Maintain and upgrade the web-based Maine Families Home Visiting Tracking System (database) and provide data collection and reports as needed. Participate in the CQI Team Maine Children s Alliance/BUILD Initiative/Urban Institute Identify appropriate uses of MaineCare that comply with CMS regulations and guidance and that are consistent with state priorities for young children. Work with OMS assisted by the National Association of State Health Policy (NASHP), the BUILD Initiative and the Urban Institute to host a state conference to identify potential changes to MaineCare rules/regulations/policies that support broader community access to EPSDT services while remaining in compliance with federal mandates. Evaluate current rules and regulations regarding EPSDT services to children, compile data on current service delivery and identify missed opportunities for achieving the expressed goals and priorities for child health in Maine. Evaluate other federally approved state plans that could provide examples for rules and policy improvement. Work closely with the Quality Counts initiative, IHOC, MaineCare Advisory Committee, Maine Equal Justice, National Association for State Health Policy and MaineHealth to develop a set of recommendations with clear benchmarks for improving access to EPSDT services based on child health data. Product: Policy brief Opportunities for Improving Access to EPSDT to the Maine Children s Growth Council (ECAC) to increase awareness of value of EPSDT. Release date: October Product: Draft recommendations for improving access to EPSDT services and other children s health services submitted to Maine s Department of Health and Human Services. Publication date: December Maine MIECHV Expansion Project HRSA : Attachment 4 1

58 Contract with local and national Medicaid experts to develop a series of proposed rules changes that will enable Maine to reach nationally established benchmarks for improving child health, in full compliance with federal rules. Host meeting with OMS staff, DHHS administrative staff and national experts to identify gaps in delivery of children s health services and create shared workplan for addressing these issues. Work with OMS and other DHHS staff to ensure that rule changes or new policies that improve child health outcomes are in compliance with federal regulations. Host monthly conference calls with OMS and national experts to provide updates on the agreed work plan. Product: Conference held in Maine sponsored by the BUILD Initiative and the Urban Institute Provide written recommendations to the Administration for development and implementation of rule changes to improve access to EPSDT for Maine children Publish a report with final recommendations for policy and rule changes acceptable to CMS with clearly defined child health benchmarks. Product: Final report with summary of recommendations that are already in the rulemaking process at OMS, along with additional recommendations that have not yet been implemented. The report will be provided to the Governor s office and the Commissioner of DHHS and will be shared with Maine Children s Growth Council (ECAC). June 2014 Maine Children s Trust Fund Provide the administration, fiscal agent/financial oversight and coordination of the Maine Families Home Visiting Training Team and the data collection, as needed Work with the Training team to identify and address needs for Home Visiting and Parent Education training and materials Coordinate contracts for training, technical assistance and continuous quality assurance, which are embedded as key performance expectations of home visiting programs as outlined in the Home Visiting Standards of Practice and the federal home visiting requirements. MCT will identify the appropriate trainers and consultants as needed, and contract directly with them. Insure the Parents As Teachers, Touchpoints, Maine Families Orientation, Great Beginnings and Infant Mental Health trainings are delivered to those needing the required trainings Support all aspects of ensuring training and fidelity to Parents as Teachers (PAT) Coordinate public awareness activities for the statewide network of home visiting programs Participate in and coordinate with the Maine Families Home Visiting Evaluation Support the Period of PURPLE Crying effort and the monitoring, coordination and tracking of the overall implementation. Maine Development Foundation Serve as the fiscal agent for the Communications Committee of the Maine Children s Growth Council (the state early childhood advisory council) to support deployment of its social marketing strategies related to MIECHV expansion project sustainability. Maine Families Home Visiting Sites Continue to provide high quality, evidence based home visiting services in accordance with the State Standards of Practice (available upon request) and with fidelity to the PAT model Participate in the CQI Team Participate in the Maine Families Home Visiting Evaluation Maine MIECHV Expansion Project HRSA : Attachment 4 2

59 Manage flex funds related to program implementation (i.e., extended stays in the NICU, treatment costs, gas cards for families in outlying rural towns) Office of Minority Health (Maine DHHS) Facilitate dialogue with the tribal nations Serve as fiscal agent for contracts for demonstration sites for direct service delivery of the Maine Families program in tribal communities Continue shared programmatic oversight of the LAUNCH grant with the MIECHV Project Director Office of Substance Abuse (Maine DHHS) Contract with the Maine Association of Substance Abuse Professionals for a Fetal Alcohol Spectrum Disorder (FASD) Coordinator to be located on-site at the Office of Substance Abuse Develop FASD strategic plan and Task Force and oversee plan implementation Conduct a FASD needs assessment Facilitate collaborative meetings in conjunction with the MIECHV project Public Health Nursing/Maine Center for Disease Control (Maine DHHS) (signed Letter of Commitment dated 6/22/11 is on file and available upon request) Support and participate in collaborative Continuum efforts across the State Offer experience and expertise in discussions around a Central Referral Concept that will benefit all partners in this collaboration Assist in the assimilation of common data sets from divergent data collection systems that will enable analysis and evaluation for the statewide Continuum. Engage the efforts of a Health Economist to help assure components are put in place for the sustainability of the Continuum. Work to expand Nursing contracts to satisfy the MCH needs in all areas of the State. University of Southern Maine Conduct qualitative and quantitative evaluation of Maine s MIECHV Expansion Program with a focus on the implementation and outcomes of the four expansion activities in this proposal, (1) increased capacity of the Maine Families (MF) program to make Parents as Teachers (PAT) accessible to all eligible families, especially vulnerable families; (2) enhancement of PAT service delivery (i.e., Linking Initiative) to include increased frequency of visits, increased clinical supervision and training, and strengthened collaboration among service providers to better serve vulnerable families; (3) increased capacity of MF sites to report required Benchmarks; and (4) increased coordination of Maine s early childhood system. Partner with the MF Program to create a joint CQI/Evaluation Advisory Committee IRB approval will be sought by the lead evaluator from the University of Southern Maine and the Maine CDC. Maine MIECHV Expansion Project HRSA : Attachment 4 3

60 ATTACHMENT 5 Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project Organizational Chart S Joint Standing Committee on Health and Human Services (Maine Legislature) Reporting per LD 1504 Sheryl Peavey Project Director Required Quarterly Report DHHS Grants Review Committee (Commissioner s Office) S Pam LaHaye Maine Families Coordinator Key Community Partners Key State Partners Key National Partners DS Maine Tribes C S C INF S Maine Families Sites (in all 16 counties) DS C Maine Children's Growth Council S C INF Department of Education Parents as Teachers National Office Melissa Wedge and TBA Clinical Consultants INF USM Epidemiology/Evaluation Team INF C Maine Children's Alliance S Maine Children 's Trust Fund INF C INF PreK Child Development Serv ices (IDEA) Federal Liaison/Race to the Top Team S C BUILD Initiative/Urban Institute S Brazelton Touchpoints Center (BTC) S INF INF S Sheri Smith Maine Touchpoints Coordinator (BTC) Medical Care Development Hornby Zeller Associates INF C C Community Caring Collaborative/ LAUNCH INF C Community Health Nursing Agencies C Early Care and Education Providers (Early/Head Start, Child Care, PreK) C Sheena Bunnell, Health Economist S Department of Health and Human Services Office of Child and Family Services (Head Start, Child Care, Child Welfare) Office of Substance Abuse Office of Maine Care Services Maine Center for Disease Control (CDC) (Title V, Public Health Nursing) Office of Minority Health Office of Information Technology Congressional Delegation S C DS INF S KEY Collaboration Efforts Direct Service Infrastructure: CQI, Evaluation, Prof. Development, Training, Data Sustainability

61 Attachment 6: Maine MIECHV Summary Progress Report (1) Maine s experience in: Implementing home visiting programs Home visiting began in Maine at the grassroots level in the late 1980 s, resulting in a diverse array of home visiting programs throughout the state. In 1997, the state used General Funds to initiate a pilot home visiting program in six counties. In 2000, the Maine Home Visiting Program was launched so that eligible families in every county could have universal access to home visiting. Initially, communities could choose from one of three models: Healthy Families America, Parents as Teachers, and a homegrown model, Parents are Teachers, Too. In 2007, under a new state administrator, home visiting sites examined the literature, came to consensus on best practices, and, with the state, established shared Standards of Practice. The Touchpoints approach was also adopted, providing a focus on reflective practice and reflective supervision; with the blessing of the Brazelton Touchpoints Center, Maine established a state Touchpoints Coordinator and Home Visiting Training Team. In 2008, Maine selected Parents as Teachers (PAT) as its statewide curriculum. The Maine PAT training team was developed and all staff became Certified Parent Educators. At that time, the state chose to use a single statewide model in order to increase commonality and consistency among program sites and provide a singular basis for performance and quality assurance. Use of a consistent curriculum and parent materials was especially important as families frequently moved from one county to another. PAT was selected because it was a national model that most program sites were already partially invested in. Maine providers preferred PAT because it was regarded as a more strength-based and respectful approach than other models and was a fit with Maine communities and programs' philosophy. In 2010, the state re-branded the network of programs as Maine Families. Today, Maine Families continues to be the core of statewide home visiting services, with trained staff in every county reaching 2,500 families per year. Maine Families sites follow rigorous Standards of Practice that include fidelity to PAT and the use of the Touchpoints approach in reflective practice and reflective supervision. Quality assurance and technical assistance are provided by an in-state team led by the Maine Families Statewide Coordinator. All Maine Families programs share a single web-based data collection system that allows for statewide evaluation and continuous quality improvement. These strategies help to ensure model fidelity, consistency, and coordination of home visiting statewide. The proposed enhanced program will be integrated into this already existing system and will build on our highly trained, highly skilled Maine Families workforce. Maine Families sites work in close collaboration with other home-based programs in the state. The Maine CDC Public Health Nursing program (and its grantees, Community Health Nursing) serves approximately 4,600 families per year statewide. On a local level, Maine Families and home-based nursing programs work closely together to ensure that family needs are met. Because the nurses work with families only for the duration of specific health needs (typically under 6 months), they frequently refer families to the Maine Families program. Maine also has Early Head Start home visiting programs in 10 of 16 counties, serving just under 500 families per year. Maine MIECHV Expansion Project HRSA : Attachment 6 1

62 (2) Maine s experience in: Integrating home visiting programs into early childhood systems Maine s home visiting providers, together with the Maine DHHS Office of Child and Family Services (OCFS), the Maine CDC, and the Maine Children s Trust Fund, have been working collaboratively to take steps toward developing a more coordinated state system. Stakeholder meetings have included Maine Families program managers, Public Health and Community Health Nursing, Early Head Start and Head Start Directors, child protective caseworkers, child welfare leadership, state agency substance abuse representatives and community providers, advocates and others. Open communication has been a hallmark of the early childhood systems work and is key to sustainability, so all relevant home visiting systems documents are online at the Maine Children s Growth Council website ( The Maine Families program is administered by Sheryl Peavey, Director of the Early Childhood Initiative from within the OCFS. Ms. Peavey has guided the development of the Early Childhood Systems Plan since the inception of the Maternal and Child Health Bureau Early Childhood Comprehensive Systems (ECCS) grant in 2004, which included home visiting as a core component from the beginning. As the Public Health Child Welfare Liaison, Ms. Peavey leads the home visiting work as a representative of both the Maine OCFS and the Maine CDC through an interagency agreement. Ms. Peavey is also responsible for staffing and coordination of the Maine Children s Growth Council, which is the state s Early Childhood Advisory Council. As history demonstrates, Maine is committed to implementation of home visiting as part of a comprehensive early childhood system one that emphasizes evidence-based practice, quality assurance, and optimal coordination of services. Maine proposes to use the MIECHV Expansion grant to further its systems-level work and enhance direct services provided by Maine Families. (3) Maine s experience in: Promoting effective policy to support and strengthen home visiting programs The following historical timeline demonstrates long-standing commitment by Maine s legislators, the governor s office, Children s Cabinet, state staff, and local providers to support and strengthen home visiting in our state: 1993 Healthy Start Task Force convened to examine Hawaii s model for CAN prevention which led to recommendation that the state pilot three Healthy Families (HF) sites Legislation was passed to develop and fund three Healthy Families sites Maine funded (using General Funds) six HF sites that were located in six counties. That same year, a Task Force to Study Strategies to Support Parents As Children s First Teachers (later known as the Task Force on Early Childhood) was legislatively convened and appointed to examine home visiting programming as a vehicle to improve child outcomes Task Force issued the first report to the Maine Governor s Children s Cabinet recommending expansion of home visiting services Task Force issued the second report to the Children s Cabinet which became the basis of legislation to create a system of home visitation using the three models Parents are Teachers, Too (PATT), PAT and HF. That same year, Legislation passed creating the Fund For Healthy Maine (tobacco settlement dollars) with home visiting selected as one of the funding focus areas. Maine MIECHV Expansion Project HRSA : Attachment 6 2

63 2006 Children s Cabinet met with Dr. T. Berry Brazelton regarding implementing Touchpoints in Maine. The Touchpoints training team was established, the home visiting system was trained and adopted the Touchpoints approach to practice Home visiting sites examined the literature and came to consensus on best practices. Standards of Practice were developed and implemented Maine adopted affiliation with PAT as the national model required of all sites. The Maine PAT training team was developed and all staff became Certified Parent Educators Home visiting sites established a common identity and became Maine Families The misguided decision by a former agency Director to eliminate all funding for Maine Families helped to bring together a strong voice for home visiting during the Legislative session, resulting in a commitment from legislators to fully restore funding and a Legislative Resolve signed by the Governor to ensure ongoing state support of home visiting. (4) Maine s experience in: Evaluating programs and using the information received to improve the quality of home visiting programs and early childhood systems Maine is committed to Continuous Quality Improvement (CQI) through regular data collection and analysis to inform changes for more effective program implementation and improved participant outcomes. Performance-based contracting is in place and will continue. Through the collection and regular use of data, Maine s home visiting programs continuously strengthen programming as well as document changes and improvements. Data is regularly reviewed at the community and state level to inform systems change. This process is facilitated by use of an online database used daily by Maine Families home visitors to document visits. This database will be updated to collect, analyze, and report on all Benchmarks and constructs. The Maine Families State Coordinator serves in the role of Quality Assurance/Technical Assistance (QA/TA) Specialist. The Coordinator and evaluators review data with provider agencies to examine successes and needed improvements. She provides TA and focuses on quality assurance practices with the Maine Families sites through monthly meetings with site managers. These meetings have led to deeper understanding of data-informed practice and decision-making, as well as provide an opportunity to create relationships that allow for open thinking, support for areas of challenge and the sharing of successful strategies. Sites are reviewed annually and receive immediate feedback on areas of strength and areas to strengthen. Managers provide quarterly narrative reports to the State. An internal comparative report focusing on performance measures is provided to all sites so they can view their data relative to others. This report will be expanded to include comparative outcome measures. (5) Maine s experience in: Improving outcomes for families served by home visiting Maine Families tracks and measures several key indicators as summarized below. Caregiver and Child Relationships. Ninety-two percent of families surveyed expressed a great to moderate increase in their confidence in parenting. Additionally, 63 % said their child greatly benefits from participation in the program. Prenatal Care. Almost 94% of expecting mothers received at least adequate prenatal services; the same percentage of all caregivers had access to a primary care provider. Maine MIECHV Expansion Project HRSA : Attachment 6 3

64 Developmental Screening and Intervention. Of all eligible children in the program, 83 % were routinely screened for developmental delays. Seven percent of those screened were referred for further evaluation, and as a result 72 % of those children initially referred through home visiting now have a formal plan and services to address developmental issues. Preventing Unintended Pregnancy. Home visitors work with families to ensure their decision to have additional children is in their family s best interest. Results from FY2010 show a 29 % increase in families using methods to prevent unplanned pregnancy from the time of their enrollment compared to most recent data. Only 6% of all families enrolled are reportedly not making any effort to prevent pregnancy. Health Care for Children. The vast majority of all infants and children in this program have insurance and access to a primary care provider (95% with insurance, 99.5% primary care provider). Likewise, 98% of all children are up-to-date on well-child exams; 93% are up-todate on childhood immunizations. Home Safety. Home visitors provide information and resources for families to assist them in understanding and addressing potential hazards in the home and automobiles. All seven categories routinely assessed with families showed a positive change in home and car safety, with the greatest improvements in outdoor environment safety, fire prevention, car safety, and choking hazards. Tobacco Use and Secondhand Smoke. Of the 698 families served by home visiting for which secondhand smoke was a concern, 44% have eliminated their child s exposure and another 28% have reduced their child s exposure. Of the 880 families where caregiver smoking was a concern, 27% report stopping use, and an additional 29% report reducing use. Protecting Children from Violence, Abuse and Neglect. Home visitors are mandated reporters of child abuse and neglect who are required to take action for the protection of children. In FY2010, 31 substantiated reports about participating families were made to the Department of Health and Human Services, Child Protective Services Division. 10 of these were made by home visitors. The reports being tracked varied in nature from witnessing abuse or neglect of a child to believing a child is at risk of being abused or neglected. The most common reason indicated for reports made (regardless of the outcome) was in the atrisk category (57%). This category was followed by suspected abuse or neglect (27%) and by witnessed abuse or neglect (15%). Increasing Family Self-Sufficiency. To help families access needed resources, program staff partner with and make a significant number of referrals to a variety of federally funded, state and community resources such as WIC, Temporary Assistance for Needy Families (TANF), childcare services, housing, legal services, transportation and counseling. Maine Families staff made more than 23,000 referrals on behalf of families in FY Surveyed families reported that having a home visitor help them make these connections is a significant benefit of their participation in the program. Nearly all enrolled families had adequate food and heat in their homes, facilitated in part by referrals of assistance to those in need. (6) Maine s experience in: Providing services to vulnerable or high-risk populations By making home visiting universally available to first-time parents and adolescent parents statewide, the Maine Families program has succeeded in decreasing the stigma that can be Maine MIECHV Expansion Project HRSA : Attachment 6 4

65 associated with home-based social services. Programs work with local hospitals and obstetricians to enroll expecting parents as early as possible. Many sites also rely on program staff from Women, Infant, and Children (WIC) to help them reach out to families. In FY2009, 35 percent of mothers enrolled prenatally; in FY2010 the program succeeded in enrolling 49 percent of participants prior to the birth of the baby. Maine s success in reaching high-risk families is reflected in data for the past year s cohort of families: 30% were parenting alone, 18%+ had not completed high school, 47% were under 22 years of age when their child was born, 36% had incomes under $10,000, 55% had incomes under $20,000, and 75% had or were eligible for Medicaid. The over 20,000 referrals made for these families are another indication of the degree of family needs identified. Many of the families served were located in rural areas and had little or no access to transportation. In addition, Maine Families is responding to a growing number of families experiencing substance abuse and a growing number of drug affected babies being referred to the program. The program has increased training for staff to respond to these growing needs, for example by providing specialized training in perinatal addiction. MIECHV Expansion funding will allow Maine Families to further expand its services to the state s most vulnerable populations by increasing service delivery staff, increasing specialized training, and supporting local linking efforts to enhance service coordination among programs. Maine MIECHV Expansion Project HRSA : Attachment 6 5

66 Attachment 7: Maine MIECHV Expansion Timeline Direct Services (Primary Staff: Maine Families Coordinator) Collaboration (Primary Staff: MIECHV Collaboration Specialist) YEAR 1 ( ) Quarter 1: Hire new staff to be placed at existing sites (2 Clinical Consultants, 25 direct service positions, 5 supervisory positions). Quarter 2: Complete training and orientation of new staff Quarters 3-4: Expand direct service delivery to reach additional 350 families statewide by end of Year 1 including families identified for Linking Services. Meet with stakeholders to assess and plan potential expansion of Maine Families to tribal communities. Develop work plan by end of Yr 1. Q3-4: Coordinate specialized training re. substance abuse, mental health, co-occurring disorders, and/or family violence for program staff and partners. Convene statewide work groups to develop recommendations: Q1-2: Definitions & Standards meets & develops recommendations Q2-3: Training & Professional Development meets & develops recommendations Q3-4: Coordinated Data Systems meets & develops recommendations Draft reports and other documents for MCGC review and public dissemination. Q1: Conduct initial training for site managers, with presentation and lessons learned from Linking pilot site (LAUNCH Bridging Program). Q1-2: Work with sites to assess local collaboration, readiness, determine next steps. Q3-4: Offer technical assistance to local coalition efforts, ongoing. YEAR 2 ( ) Q1: Hire additional staff (15 direct service positions) Q2: Complete training/orientation of new staff Q3-4: By end of Year 1, reach 900 families ( ) statewide per year including families identified for Linking Services. Begin implementation of program expansion to tribal communities as determined by ongoing assessment and planning. Clinical consultants provide support to program staff (ongoing through Year 4). Additional inter-agency trainings organized and delivered based on community needs (ongoing through Year 4). Q1-2: Quality Assurance meets & develops recommendations Q2-3:Financing & Sustainability meets & develops recommendations Draft reports and other documents for MCGC review and public dissemination (ongoing through Yr 4). Develop & distribute templates/ tools, e.g. MOU s, universal intake form. Continue to offer technical assistance to local coalitions (Ongoing through Yr 4) Facilitate quarterly Linking discussion among site managers to share progress, challenges, ideas (through Yr 4) YEAR 3 ( ) Q1: Hire additional staff (15 direct service positions) Q2: Complete training and orientation of new staff; expanded training (ages 3-5) for existing staff. Q3-4: By end of Year 1, reach 1300 families ( ) statewide per year including families identified for Linking Services. Continue expansion to tribal communities as determined by ongoing assessment and planning. Continue to convene statewide work groups to guide implementation & follow up, ongoing. Draft reports and other documents for MCGC review and public dissemination (ongoing through Yr 4). Support documentation of collaboration process in conjunction with Evaluation Team YEAR 4 ( ) Q1: Hire additional staff (15 direct service positions) Q2: Complete training and orientation of new staff; expanded training (ages 3-5) for existing staff. Q3-4: By end of Year 1, reach 1700 families ( ) statewide per year including families identified for Linking Services. Continue expansion to tribal communities as determined by ongoing assessment and planning. Draft reports and other documents for MCGC review and public dissemination (ongoing through Yr 4). Support documentation of collaboration process in conjunction with Evaluation Team Maine MIECHV Expansion Project: Attachment 7 1

67 Evaluation (Primary Staff: Univ of Southern Maine Team) Sustainability (Primary Staff: MIECHV Project Director) YEAR 1 ( ) Convene Joint CQI/Evaluation Team (through Year 4) Revise evaluation plan based on advisory committee feedback Complete Contextual/Agency assessments using administrative data Review and enhance MF data system to ensure benchmark data collection Compile benchmark data and submit (ongoing annually through Yr 4) Develop staff and participant survey tools Develop staff, participant and agency director interview questions Modify collaboration survey Work with Maine Children s Growth Council (MCGC) Communications Committee on social marketing plans o Messaging training for MIECHV sites o Daily Facts to Legislature (2012 Public Policy Campaign) o Broadcast time for TV ads o Development of collateral materials o Plan for print media (op-eds, features) Share MIECHV progress with Maine Children s Growth Council and facilitate Council review and decision-making Meet quarterly with DHHS Commissioner s Grant Review Committee Prepare DHHS report per LD 1504 to Joint Standing Committee on Health and Human Services, including legislation as needed Coordinate with Maine Children s Alliance to host meeting with DHHS Medicaid staff, DHHS administrative staff and national experts (BUILD/Urban Institute) to identify gaps in the delivery of children s health services and create a shared work plan for addressing these issues. Provide updates to Congressional Delegation (and include in media distribution efforts) YEAR 2 ( ) Convene Joint CQI/Evaluation Team Administer staff and participant surveys Conduct interviews with staff, participants, agency directors, key collaborators Administer collaboration survey Analyze baseline qualitative and quantitative data Present collaboration work group recommendations to MCGC and facilitate Council review and decision-making. Continue print and visual media campaign Daily Facts to Legislature (2013 Public Policy Campaign) Provide updates to Congressional Delegation (and include in media distribution efforts) Meet quarterly with DHHS Commissioner s Grant Review Cmte Coordinate MIECHV work with Project LAUNCH to review sustainability issues and new opportunities Provide written recommendations to the Executive Branch for potential rule changes to improve access to EPSDT for Maine children Provide updates to Congressional Delegation (and include in media distribution efforts) YEAR 3 ( ) Convene Joint CQI/Evaluation Team Conduct interviews with staff, participants, agency directors, key collaborators Administer collaboration survey Present progress reports to MCGC and facilitate Council review and decision-making. Continue print and visual media campaign Daily Facts to Legislature (2014 Public Policy Campaign) Provide updates to Congressional Delegation (and include in media distribution efforts) Meet quarterly with DHHS Commissioner s Grant Review Committee With MCA, finalize report with recommendations for policy and rule changes acceptable to CMS with clearly defined child health benchmarks Provide updates to Congressional Delegation (and include in media distribution efforts) YEAR 4 ( ) Convene Joint CQI/Evaluation Team Administer staff and participant surveys Administer collaboration survey Complete all analyses Complete evaluation report Disseminate report findings to key stakeholders Present reports of progress MCGC and facilitate Council review and decision-making. Continue print and visual media campaign Daily Facts to Legislature (2015 Public Policy Campaign) Provide updates to Congressional Delegation (and include in media distribution efforts) Meet quarterly with DHHS Commissioner s Grant Review Committee Provide final report to Congressional Delegation (and include in media distribution efforts) Maine MIECHV Expansion Project: Attachment 7 2

68

69 Attachment 9: Other Relevant Documents Table of Contents: Letter of Support from the Passamaquoddy Tribal Council Letter of Support from the Maine Children s Alliance/BUILD Initiative/Urban Institute Letter of Support from US Congresswoman Chellie Pingree Letter of Support from US Senator Susan Collins Copy of LD 1504: Resolve to Ensure a Strong Start for Maine's Infants and Toddlers by Extending the Reach of High-quality Home Visitation, signed into law in June 2011 Maine MIECHV Expansion Project HRSA : Attachment 9

70

71 VOICES FOR MAINE S CHILDREN July 1, 2011 Sheryl Peavey, ECCS Director Division of Early Childhood, Maine Department of Health & Human Services 2 Anthony Avenue Augusta, ME Dear Sheryl, The Maine Children s Alliance is pleased to continue our partnership in developing systemic improvements to better help Maine children and families. Our work with the home visiting system and efforts to increase cross system engagement remains one of our top priorities. The Maine Children s Alliance intends to bring a number of resources to the work of exploring new ways to support home visitation and improve child health outcomes. We have been working closely with one of our national affiliates, the Annie E. Casey Foundation to provide an analysis of the opportunities and challenges in current Medicaid policy. We will also provide technical assistance and support from two of our national partners from the Birth to Five Policy Alliance. The Urban Institute and BUILD will provide meeting support; facilitation and guidance as we gather together state staff to discuss how to improve access to services for Maine s youngest children in particular. Thank you for all the hard work you do on behalf of Maine s children and families. We look forward to this new chapter in our work together. Sincerely, Dean Crocker President/CEO 303 State Street Augusta, Maine (207) fax: (207) [email protected]

72

73

74

75

76

77

78

79

80