PROGRAM NAME HERE
Annual Service
Review
Reporting Period: July 1, 2013- June 30, 2014
The “Annual Service Review” is an analysis of your Healthy Families-TIP Program’s
service delivery. It also incorporates the “Cultural Sensitivity Review” (Critical Element
5) and the Quality Assurance Plan (Governance and Administration). The Annual Service
Review, Cultural Sensitivity Review and Quality Assurance Plan are required by Healthy
Families America (HFA) for accreditation purposes. The ASR is due 90 days after the
completion of the contract year. Although individual sites may have different contract
years, we are all now reporting on a July 1-June 30 timeframe for DCF, so all sites will
now have their ASR’s due to PCANJ by September 30th of each year.
Program Name Here
Annual Service Review
Reporting Period: July 1, 2013- June 30, 2014
I: Program information
Write a narrative with the following information:
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Agency name and location
FTE FSWs
FTE FAWs
FTE Supervisor
FTE Program Manager
FTE Data Entry
Expected Case Weight
Number of new enrollments
Number of discharges
II: Target Population (CE 1)
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Define what your target population is and describe how it was decided upon. Include relevant and
up-to-date community data that was used to determine the target population. Both the definition
and data utilized should be comprehensive and updated within the past two years. (1-1.A)
If you are part of a Central Intake, describe this process.
State the percentage of families you were able to screen within your target population.
If the percentage is less than 90% please describe the strategies you have identified and
implemented to increase the percentage of the target population that are screened. (1-1.C)
o It is recommended to identify how you can improve the current system of relationships, and
form new relationships.
III: Screening Process (CE 1)
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What is your Assessment Acceptance Rate?
Describe how you monitor and address the screening/identifying process for families that screen
positive but were not offered an assessment.(1-2.D)
Explain why some families were not assessed after a positive screen?
What strategies have you developed and implemented to increase the number of positive screens
that are assessed?
IV: Assessment Process (CE 1)
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What is your Verbal Program Refusal Rate?
Describe how you monitor and address families who verbally declined the offer of services after a
positive assessment? (1-2.E)
What are some of the reasons why families verbally refused services after a positive assessment?
July 2014
Program Name Here
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What strategies have you developed and implemented to lower the number of families that decline
the offer of services after a positive assessment?
What is the percentage of assessments that occur prenatally and within the first 2 weeks after the
birth of the child? (1-2.C)
o If the percentage is under 95%, describe your plan for improvement.
V: Program Acceptance Rate (CE 1)
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What is your Program Acceptance Rate percentage? (1-4.A)
Provide a “comprehensive” analysis between families that enroll versus those that never enroll after
an assessment. (CE 1-4.B)
o Both formal (data collection) and informal (discussions with staff) methods can be used.
o The analysis must include significant programmatic, demographic and social factors.
o Once an analysis is complete, make a comparison between those who enroll and those who
do not enroll.
o If at least 90% of your families offered services over a two year time frame accepted services
by receiving the first home visit, an analysis is not required.
Based on your “comprehensive” analysis, describe the plan you have developed and implemented to
improve the acceptance rate. (CE 1-4.C)
o The plan must address the programmatic, demographic and/or social factors identified
within the analysis.
o If at least 90% of your families offered services over a two year time frame accepted services
by receiving the first home visit, a plan is not required.
What percentage of enrollments occurred before the target child was 3 months old? (1-3.B)
o Exclude any cases in which TC was hospitalized in the NICU after birth.
o If the percentage is less than 95%, describe the plan you have developed and implemented
to improve this rate.
VI: Family Retention Rates (CE 3-4.A, B, C)
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By using HFA methodology, calculate the length of time families are retained in services. (3-4.A)
What is your retention rate % for families enrolled within the following timeframes:
o 6 months
o 12 months
o 18 months
o 24 months
Provide a “comprehensive” analysis between families that remain and those that leave the program.
The analysis must be comprehensive, addressing all significant programmatic, demographic and
social factors. (3-4.B)
Describe the plan you have developed and implemented to increase your retention rate. The plan
must address all the programmatic, demographic and/or social factors discussed in the analysis. (34.C)
July 2014
Program Name Here
VII: Cultural Sensitivity Review (CE 5)
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Describe the ethnical, racial, language, demographic and other cultural characteristics of your Service
Population.(5-1)
Identify similarities and gaps between your target population and service population.
Identify similarities and gaps between staff and your service population.
How are ethnic, racial, language, demographic and other cultural characteristics taken into account
in overseeing staff-family interactions? (5-2.B)
o Supervision is the ideal opportunity to monitor home visitor-family interactions. In addition,
ongoing case reviews and shadowing home visits can be used to ensure staff is respecting
the family’s values and cultural characteristics.
Show how your program is able to provide culturally sensitive and family-centered services to the
major group of your service population through the following: (5-2.A)
o Materials- flyers, brochures, annual report, curricula, etc.
o Staff- how the selection of staff is meeting the cultural needs of the families, including
demographic information, language, life experiences, religion, geography, etc…
o Community Partners- identifying providers in the community that can provide additional
support and services to the major groups within the service population.
How does your program ensure that all aspects of its service delivery (assessment, home visitation
and supervision) are culturally sensitive:
o Assessment- timeliness of assessments, organizational relationships, reviewing the analysis
of who is refusing services.
o Home Visitation- Creative outreach, home visit achievement rates, IFSPs, immunizations,
home visitor assignment, reviewing the analysis, and plans of family retention.
o Supervision: assignment of staff, how the supervisor takes into account the cultural
characteristics of staff and families, cultural aspects of staff retention, support of additional
training based on cultural characteristics, diversity of the advisory group.
Demonstrate input on your program’s service delivery from:
o Staff
o Families
o Advisory Board
What training did you provide staff during the past year that is related to the cultural characteristics
of the service population? (5-3)
o The characteristics of the service population should be used to identify this training.
Identify patterns and trends related to site strengths as well as areas to improve upon.
VIII: Staff Retention and Satisfaction (CE 9-4)
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State how many FTE positions you had during the past year.
State the number of staff that filled those positions.
State the number of staff that left within the past year and why.
Describe how you monitor staff satisfaction.
o Surveys, exit interviews, team meetings, individual supervision, Monthly Development
Checklists
What strategies have you developed and implemented to address any issues with staff retention and
satisfaction?
July 2014
Program Name Here
VIIII: Medical Home and Referral Sources (CE 6 & 7)
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Provide evidence that the program monitors and provides information, referrals, linkages and followups to all participating family members on available health care, health care resources and
community services when necessary.
o If families were not connected to services, provide a narrative.
How does the program track target children suspected of having developmental delays? How does
the site follow up with these families? (6-7.B)
State the percentage for each outcome. If your program does not meet any of the following
achievements, provide an improvement plan.
o 90% of eligible children that have health insurance (7-3.B)
o 95% of children have a primary care provider (7-1.B)
o 85% of children that are up-to-date on Well-Baby visits (7-3.A&B)
o 90% of children that are up-to-date with developmental screens (6-6.A&B)
o 90% of children that are up-to-date with immunizations (7-2.B)
X: Home Visit Completion Rate (4-2.B&C)
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State the number and percentage of home visits completed during the past year. If the
percentage is less than 75% of those expected, describe your plan you developed and
implemented to improve this area.
XI: Quality Assurance Plan (GA-3.A&B)
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Summarize your conclusions regarding the quality of your program in all service areas stated in the
highlighted (yellow) areas above.
Describe your follow up mechanisms for making sure that the plans for improvement are
implemented. State specific timelines or goal dates.
July 2014
Program Name Here
SECTION
DEFINITION/ DESCRIPTION
HFA
STANDARDS
CORRESPONDING FAMSYS REPORTS
MANUAL TRACKING
AND REPORTING/ HFA
DATA SHEETS
# of births in your target
population can be found
in Censuses, MaternalChild Health
consortiums.
% of target
population
screened
The number of screens divided by the number of
births in your target population
1-1.C
Run the Served Cases- Screens Report for the total # of screens completed
within a specific time period.
FamSys does not track the number of total number of births within your target
population
Assessments
completed before
TC is 2 weeks old
The total number of assessments completed before
TC was two weeks old divided by the total amount
of assessments completed.
1-2.C
Run the 1.1-D. Assessment Information Report.
n/a
Assessment
Acceptance Rate
The number of families during a specific time
period, who completed assessments divided by the
number of families who, during the same time
period, screened positive, but were not assessed.
1-2.D
Run the Screen/Referral Source Summary report for the total number of
positive screens and run the Served Cases: KEMPE Report for the total
number of assessments completed within a specific time period.
n/a
Verbal Program
Refusal Rate
The number of families during a specific time
period, who assessed positive and verbally declined
the offer of home visiting services.
1-2.E
Program
Acceptance Rate
The total number of families who accepted home
visiting services and had a home visit divided by
those who were offered home visiting services and
but did not complete a home visit.
1-4.A
Program
Acceptance-Analysis
The analysis between families that enroll into
services and families that never enroll after an
assessment.
1-4.B
Run the 1-4.A-B Program Acceptance Rate & 1-2.E Verbal Refusal Rate and
create an analysis between Enrolled and Not Enrolled families.
Family Retention
Rate
The percentage of families who remain in the
program over specified periods of time (6 months,
12 months, 24 months, etc.) after receiving the 1st
home visit (intake).
First, select a specified time period. The time period
3-4.A
The FamSys Report 3-4A. & B. Retention Rate Analysis will provide the
percentage of families who remain in the program over specified periods of
time. FamSys measures retention at the following intervals; 6 months, 12
months, 1 year and 2 years. The report also compares several characteristics
(the report itself is 4 pages long) between discharged families and those who
Run the 1-4.A-B Program Acceptance Rate & 1-2.E Verbal Refusal Rate and
look at the 3rd column labeled “Participant Refusal”
Run the 1-4.A-B Program Acceptance Rate & 1-2.E Verbal Refusal Rate. The
rate will appear in the 1st column labeled “Enrolled”.
July 2014
HFA Form: 1-1.C_1-2.CE_1-3.B_1-4.A-C
Screening/Assessment
Data & Acceptance
Analysis Grid
HFA Form: 1-1.C_1-2.CE_1-3.B_1-4.A-C
Screening/Assessment
Data & Acceptance
Analysis Grid
HFA Form: 1-1.C_1-2.CE_1-3.B_1-4.A-C
Screening/Assessment
Data & Acceptance
Analysis Grid
HFA Form: 3-4.A
Retention Measurement
Worksheet
Program Name Here
must be selected that ended at least one year ago
for one year retention rate, two years ago for two
year retention rate, three years ago for three year
retention rate, and so on. This is to ensure that all
families beginning services during the specified
time period have had the opportunity to stay for
the full retention period being measured. For
example, a family enrolled in December 2012 could
not be counted as retained for one year until
December 2013.
remained during each interval.
For the report, you need to enter the volume year you are using. For example,
if you want to measure 2 year retention, you would use 7/1/11 as the START
DATE and 6/30/12 as the END DATE. The report will then calculate retention
for 2 years.
Do not use the retention rates in the DCF Report.
Family Retention
Analysis
The analysis between families that remain in the
program and those that are discharged (Excludes
those where Discharge Reason is 'Out of Target',
'Pregnancy Terminated/Miscarriage' or 'TC Died)
within specified time period.
3-4.B
New Enrollments
New families that enrolled (have an intake date).
n/a
Discharges
Families that were discharged from the program.
n/a
Service Population
Referral Sources
and Services for
Families
Members of the Target Population receiving
services. The program should be able to address all
the ethnic and/or racial, language, demographic
and other cultural characteristics which include:
Age, Family Composition, Income, Employment,
Marital Status, Language, Religion, Education,
Criminal history, Domestic Violence, Substance
Abuse, Special Needs, Mental Health Issues,
Geographic’s Characteristics.
Linking the family to services such as child care,
school readiness, job training, family support,
substance abuse treatment, mental health
treatment and domestic violence resources.
The FamSys Report 3-4A. & B. Retention Rate Analysis will provide
Demographic and Social factors. Only 2 Programmatic factors are covered in
this report on page 4: Cases with >1 Home Visitor & PC’s Trimester @ intake.
The analysis pulls characteristics from the Intake form and Discharge follow-up
form.
Run the Served Cases Report: New Families Enrolled in Time Period for the
total number of new enrollments.
Run the Served Cases Report: Families Discharged in Time Period for total
number of discharges.
Other programmatic
factors such as the
Target Population,
Referral Sources,
Staffing Issues (patterns
& trends) # of days
between screen to
assessment, assessment
to intake, training of
staff, etc…
n/a
n/a
5-1
Demographic information can be pulled from the Demographic Report. It
pulls families enrolled within a specific timeframe.
n/a
7-3.C
Run the Service Referrals Arranged and Service Referrals
Information/Discussion reports.
n/a
July 2014
Program Name Here
Follow ups to
Referral Sources
and Services
Medical/ Health
Care Providers
Tracking and following up if the family received the
services that they were referred to.
7-3.D
Run the Service Referrals Needing Follow-Up Report
n/a
Linking the child to medical providers to assure
optimal health and development.
7-1. B
Run the Medical Provider Listing Report.
n/a
7-2.B
Run the Target Child Immunizations Record Report.
Run the Target Child Immunizations Record Exclusions to determine if any
Target Children are excluded because of religious, ethical or permanent
medical reasons.
n/a
Immunizations
Educating the family on the importance of
immunizations and tracking the receipt of
immunizations.
Enrollment before
TC is 3 months old
The number of families enrolled into services
before TC is three weeks old. Excluded families
where TC was in the NICU after birth and could not
start services before 3 months.
1-3.B
Run the Timing of First Home Visit Report.
# of families whose TC
was in the NICU after
birth and started
services after 3 months.
The number of eligible children that have health
insurance.
7-3.B
Run the DCF Report 9.a.
n/a
The number of children that have a primary care
provider.
7-1.B
Run the Medical Provider Listing Report OR
Run the DCF Report 9.b.
n/a
Well-Baby Visits
The number of children up-to-date with Well-Baby
Visits
7-4.B
Run the DCF Report 9.c.
n/a
Developmental
Screens
The number of children up-to-date for
developmental screens
6-6.B
Home Visit
Completion Rate
The Home Visit Completion rate by family for the
year
4-2.B&C
Eligible Children
have Health
Insurance
Children have a
Primary Care
Provider
Run the DCF Report 9.d.
Run the DCF Report and review 9.d.1 to determine if any child who scored
under the cutoff received a referral/follow-up.
Run the 4-2B. Home Visit Achievement Rate – Detail Report and Exclude all
Level X and TR families.
July 2014
HFA Form: 6-6.B ASQ
Tracking Form
HFA Form: 4-2.B
Tracking Form