Healthy Families Arizona Annual Evaluation Report - FY2015 July 2014 – June 2015 Healthy Families Arizona, Annual Evaluation Report 2015 July 2014 – June 2015 Submitted to: Healthy Families Arizona Arizona Department of Child Safety Office of Prevention and Family Support 3003 N. Central Ave. Phoenix, AZ 85012 Ph: (602) 255-2667 Fax: (602) 255-3261 Submitted by: LeCroy & Milligan Associates, Inc. 2020 N. Forbes Blvd. Suite 104 Tucson, AZ 85745 Ph: (520) 326-5154 Fax: (520) 326-5155 www.lecroymilligan.com Acknowledgments: This evaluation report represents the efforts of many individuals and many collaborating organizations. The evaluation team for Healthy Families Arizona (HFAz) that contributed to this year’s report includes evaluators Darlene Lopez, ABD, Steven Wind, Ph.D., Craig W. LeCroy, Ph.D., Michel Lahti, Ph.D., Kerry Milligan, MSSW, Olga Valenzuela, B.A, and data management staff, Veronica Urcadez, Eloina Cardenas, Frankie Valenzuela, and Kendra Ortiz. We extend appreciation to Jenna Shroyer, Manager, and Esthela Navarro, HFAz Statewide Program Coordinator, in the Office of Prevention and Family Support, for their guidance and support. The members of the Healthy Families Arizona Advisory Board are thanked for their long term commitment, enthusiasm and leadership in Arizona (a list of members is included in the appendices). Thank you to the Healthy Families Arizona program managers and supervisors, who have worked diligently to ensure data are collected, submitted, and shared with staff for program improvement. Family Assessment Workers, Family Support Specialists and support staff at the sites have dutifully collected the data, and have participated in the evaluation process--all of whom help to tell an accurate story about Healthy Families Arizona. Lastly, we acknowledge the families who have received Healthy Families Arizona services. About LeCroy & Milligan Associates: Founded in 1991, LeCroy & Milligan Associates, Inc. is a consulting firm specializing in social services and education program evaluation and training that is comprehensive, research-driven and useful. Our goal is to provide effective program evaluation and training that enables stakeholders to document outcomes, provide accountability, and engage in continuous program improvement. With central offices located in Tucson, Arizona, LeCroy & Milligan Associates has worked at the local, state and national level with a broad spectrum of social services, criminal justice, education and behavioral health programs. Suggested Citation: Healthy Families Arizona, Annual Evaluation Report FY2015, LeCroy & Milligan Associates, Inc. (2015) Table of Contents Executive Summary ........................................................................................................................... 4 Introduction ........................................................................................................................................ 8 Healthy Families Arizona Statewide System ............................................................................. 8 In This Report ................................................................................................................................... 10 Evaluation Methodology............................................................................................................. 10 Review of Current Literature ..................................................................................................... 12 Program Updates ............................................................................................................................. 16 Training and Professional Development .................................................................................. 16 MIECHV Grant ............................................................................................................................. 17 Quality Assurance and Training Assistance ............................................................................ 17 Collaboration between First Things First and Arizona Department of Health Services ... 18 Healthy Families Arizona Participant Characteristics ................................................................ 19 Length of Time in Program and Reasons for Termination..................................................... 21 Maternal Risk Factors .................................................................................................................. 23 Infant Characteristics ................................................................................................................... 24 Race and Ethnicity........................................................................................................................ 25 Assessment of Risk Factors ......................................................................................................... 26 Summary ....................................................................................................................................... 28 Key Healthy Families Arizona Services ........................................................................................ 29 Developmental Screens and Referrals for Children ................................................................ 29 Outcomes for Families ..................................................................................................................... 31 Parent outcomes ........................................................................................................................... 31 Healthy Families Parenting Inventory Reveals Positive Parent Change ......................... 31 Healthy Families Parent Inventory (HFPI) Subscales ......................................................... 32 Total Change Score on the HFPI ............................................................................................ 33 Child Abuse and Neglect ............................................................................................................ 33 Collaboration with the Department of Child Safety ............................................................... 35 Child Development and Wellness ............................................................................................. 36 Immunizations .......................................................................................................................... 36 Safety Practices in the Home .................................................................................................. 37 Mothers’ Health, Education, and Employment ....................................................................... 39 Subsequent Pregnancies and Birth Spacing ......................................................................... 39 School, Educational Enrollment, and Employment ............................................................ 40 Substance Abuse Screening ........................................................................................................ 41 2015 Participant Satisfaction Survey.......................................................................................... 42 Healthy Families Arizona Annual Evaluation Report 2015 1 Conclusions and Recommendations ............................................................................................. 44 References.......................................................................................................................................... 46 Appendix A. Team Level Data ....................................................................................................... 49 Appendix B. Healthy Families Arizona Steering Committee Members .................................. 60 Appendix C. Parent Survey ............................................................................................................ 61 Appendix D. Healthy Families Arizona Prenatal Logic Model................................................. 62 Appendix E. Healthy Families Arizona Postnatal Logic Model................................................ 63 Healthy Families Arizona Annual Evaluation Report 2015 2 List of Exhibits Exhibit 1. Healthy Families Arizona Program Sites in State Fiscal Year 2015 .......................... 9 Exhibit 2. Participants Included in the Evaluation for State Fiscal Year 2015 ........................ 20 Exhibit 3. Length of Time to Closure in Days for State Fiscal Years 2012 to 2015 .................. 21 Exhibit 4. Families’ Length of Time to Closure for State Fiscal Year 2015 ............................... 22 Exhibit 5. Most Frequent Reasons for Termination State Fiscal Year 2015 .............................. 22 Exhibit 6. Selected Risk Factors for Mothers at Intake State Fiscal Year 2015 ......................... 23 Exhibit 7. Risk Factors for Infants - State Fiscal Year 2015 ........................................................ 24 Exhibit 8. Parent’s Ethnicity State Fiscal Year 2015 .................................................................... 25 Exhibit 9. Mother’s Race* State Fiscal Year 2015......................................................................... 25 Exhibit 10. Father’s Race* State Fiscal Year 2015 ........................................................................ 26 Exhibit 11. Percentage of Parents Rated Severe on Parent Survey Items ................................ 27 Exhibit 12. Percentage of Parents Rated Severe on Parent Survey Items ................................ 27 Exhibit 13. ASQ-3 Screening State Fiscal Year 2015 .................................................................... 29 Exhibit 14. ASQ-3 Follow-up Services State Fiscal Year 2015 .................................................... 30 Exhibit 15. Change in Subscales of the HFPI ............................................................................... 32 Exhibit 16. Overall Change in Healthy Families Parenting Inventory Outcomes .................. 33 Exhibit 17. Percent of Families Showing No Child Abuse and Neglect Incidences ............... 35 Exhibit 18. Immunization Rate of Healthy Families Arizona Children ................................... 37 Exhibit 19. Percent of all Families Implementing Safety Practices ............................................ 38 Exhibit 20. Percentage of Mothers who Reported Subsequent Pregnancies State Fiscal Years 2012 to 2015............................................................................................................................... 39 Exhibit 21. Length of Time to Subsequent Pregnancy for Those Families with Subsequent Births for Fiscal Years 2012 to 2015 ....................................................................................... 40 Exhibit 22. Percent of Mothers Enrolled in School – State Fiscal Year 2015............................. 40 Exhibit 23. Mother’s Employment Status ..................................................................................... 41 Exhibit 24. Percent Screened and Assessed Positive on the CRAFFT....................................... 42 Exhibit 25. Percent Who Strongly Agreed on Satisfaction Survey Statements 2015............... 43 Healthy Families Arizona Annual Evaluation Report 2015 3 Executive Summary The Healthy Families program model is designed to help expectant and new parents get their children off to a healthy start. Families are screened according to specific criteria and participate voluntarily in the program. Families that choose to participate receive home visits and referrals from trained staff. The Healthy Families Arizona program serves families with multiple stressors and risk factors that can increase the likelihood that their children may suffer from abuse, neglect, or other poor outcomes. By providing services to under-resourced, stressed, and overburdened families, the Healthy Families Arizona program fits into a continuum of services provided to Arizona families. The Healthy Families Arizona Program Healthy Families Arizona is in its twenty-fourth year, and is modeled after and accredited with the Healthy Families America initiative under the auspices of Prevent Child Abuse America. In State Fiscal Year 2015, with combined funding from the Arizona Department of Child Safety (DCS), First Things First (FTF), and the Department of Health Services (DHS) funding, Healthy Families Arizona provided services to families in 13 counties through 12 sites and 41 teams. Who Does Healthy Families Arizona Serve? A total of 4,911 families were monitored for evaluation purposes during the current study year from July 1, 2014 through June 30, 2015. The evaluation of the statewide Healthy Families Arizona system covers only families with children that are 24 months old or younger (n=4,191) The remaining 720 families’ children were between 24 and 60 months, so were not included in the evaluation. In order to have a meaningful evaluation of the program effects, only the families that receive at least a minimal amount of program exposure are included. This further restricts our dataset to 3,455 families that have received at least four home visits. Slightly less than one fourth of the families enter in the prenatal period and the average length of time in the program is just under 12 months. Healthy Families Arizona Annual Evaluation Report 2015 4 Healthy Families Arizona program families have a significant number of maternal and infant risk factors at entry into the program compared to the overall state rates. The mothers enrolled into Healthy Families Arizona are more likely to be teen parents, single parents, unemployed, undereducated, living in poverty, and receiving state funded insurance through the Arizona Health Care Cost Containment System (AHCCCS). The infants are also more likely to suffer from birth defects, be of low birth weight, be born preterm, and have positive alcohol or drug screens at birth than for Arizona as a whole as reported in state and federal data. Risk Factors of Mothers Teen Births (19 years or less) Births to Single Parents Less Than High School Education Not Employed No Health Insurance Receives AHCCCS Late or No Prenatal Care Median Yearly Income Risk Factors for Infants Born < 37 weeks gestation Birth Defects Low Birth Weight Positive Alcohol/Drug Screen Healthy Families Arizona Prenatal Families Healthy Families Arizona Postnatal Families Arizona State Rates 18.5% 71.4% 35.5% 73.6% 4.4% 88.0% 27.1% $10,800 14.1% 71.8% 35.8% 78.1% 6.1% 81.9% 35.6% $12,000 8.5% 45.1% 17.6% 45.8% 3.6% 53.8% 18.7% $50,068 Healthy Families Arizona Prenatal Families Healthy Families Arizona Postnatal Families Arizona State Rates 9.7% 1.1% 8.2% 1.6% 16.0% 0.8% 13.5% 10.2% 9.0% 0.7% 6.9% 1.6% Sources: Arizona State Rates come from 2013 data from the Arizona Department of Health Services Vital Statistics records, and the U.S. Census Bureau, American Community Survey, 2013. The Prenatal and Postnatal Families data comes from the Evaluation dataset. Outcomes for Families and Children Participating in Healthy Families The Healthy Families Parenting Inventory (HFPI) revealed statistically significant improvement on all subscales at 6 months, and all at 12 months except social support. This indicated that Healthy Families Arizona participants are continuing to see reductions in their risk factors related to child abuse and neglect. Healthy Families Arizona Annual Evaluation Report 2015 5 Parents in Healthy Families report significant changes in: • Increased problem solving • Increased personal care • Improved mobilization of resources • Increased parenting role satisfaction • Improved parent/child interaction • Improved home environment • Improved parenting efficacy • Decreased depression Child Development and Wellness Timely immunizations remain an important component for positive child health and development outcomes. The immunization rate for the children of Healthy Families Arizona participants by 24 months was 71.0% compared to a 74.6% immunization rate for 2 year-olds in the state of Arizona as a whole. Healthy Families Arizona also educates families on home safety practices. Results indicate that for families who have been in the program for 12 months: 99.8% of participants are using car seats, 95.8% have poisons locked, and 91.6% have working smoke alarms. Developmental delays are screened for at regular intervals in the Healthy Families Arizona program to assure that children who need further services are referred appropriately to local community services and other medical homes in order to promote for the families to access their available concrete supports. For 2014-2015 approximately 85% of 2-year olds in the program were screened for developmental delays. Child Abuse and Neglect Records of child abuse and neglect incidents (substantiated) were examined for program participants who had received services for at least six months. A total of 114 Healthy Families Arizona families had a substantiated case of child abuse and/or neglect out of 2,658 families that had participated in the program for at least 6 months. Healthy Families Arizona teams also provided voluntary home visitation services to a total of 618 families that were involved with the Department of Child Safety (DCS), previously known as Child Protective Services. Mothers’ Health, Education, and Employment Healthy Families Arizona also seeks to improve the health, education, and employment outcomes among mothers to increase their resilience and so they are better equipped to meet their families’ needs. Research shows that spacing pregnancies at least 24 months apart has positive health benefits for the mother. This year 0.9% of mothers with a subsequent pregnancy waited over 24 months before they got pregnant with their next Healthy Families Arizona Annual Evaluation Report 2015 6 child. The number of mothers enrolled in school has continued to decrease in recent years, with 12.8% enrolled at 1 year of program participation, and 11.7% at 2 years. The home visitors also complete screenings and provide referrals for mental health services and substance abuse problems. Substance abuse continues to be a difficult problem for families, but is less than in fiscal year 2014. Approximately 41% of the participants were screened as having a history of substance abuse problems at intake, with nearly 7.5% continuing to have problems after six months in the program, down from 12% in 2014. Healthy Families Arizona Annual Evaluation Report 2015 7 Introduction Healthy Families Arizona was established in 1991 by the Arizona Department of Economic Security (now known as the Arizona Department of Child Safety) as a home visitation service for at-risk families, and is now in its 24th year. The Healthy Families Arizona program is accredited by Prevent Child Abuse America and is modeled after the Healthy Families America initiative. Healthy Families America began under the auspices of Prevent Child Abuse America (formerly known as the National Committee to Prevent Child Abuse) in partnership with the Ronald McDonald House Charities. Healthy Families America was designed to promote positive parenting, enhance child health and development, and prevent child abuse and neglect. Healthy Families America has nearly 630 affiliated program sites in 40 States, the District of Columbia, American Samoa, Guam, Northern Mariana Islands, Puerto Rico, US Virgin Islands, and Canada. Healthy Families America is approved as an “evidence-based early childhood home visiting service delivery model” by the US Department of Health and Human Services. The program model of Healthy Families is designed to help expectant and new parents get their children off to a healthy start. Families are screened according to specific criteria and participate voluntarily in the program. Trained staff provide home visits and referrals to families that choose to participate. By providing services to under-resourced, stressed, and overburdened families, the Healthy Families Arizona program fits into a continuum of services provided to Arizona families. Healthy Families Arizona Statewide System Healthy Families Arizona is a multi-site statewide system. The Office of Prevention and Family Support under the Arizona Department of Child Safety is designated as the Central Administration for all accredited Healthy Families Arizona sites. The variety of functions performed by Central Administration is designed to support the multi-site system and include quality assurance, evaluation, training and technical assistance, system-wide policy development, and administration. Each of these functions covers a set of activities and tasks that guide operations at the Central Administration level as well as at program level. The funding structure for the Healthy Families Arizona Program is supported by three state agencies: the Arizona Department of Child Safety (DCS), First Things First (FTF), and the Arizona Department of Health Services (DHS). The DCS Central Administration supports collaboration with the three state agencies in a fully integrated system to enhance the quality of Healthy Families Services. In State Fiscal Year 2015, funding level for the statewide system included $7,161,984 from DCS, $5,915,520 from FTF, and $4,813,024 from DHS. The combined funding of $17,890,528 Healthy Families Arizona Annual Evaluation Report 2015 8 from DCS, FTF, and DHS allows the Healthy Families Arizona sites and teams to provide services to families living in 13 counties and 244 zip code areas around Arizona. For the 2015 state fiscal year, there were 12 sites and 41 home visitor teams (12 DCS funded, 7 FTF funded, 9 MIECHV funded, and 13 receiving funding from more than one source). See Exhibit 1 for a list of teams funded in Fiscal Year 2015. Exhibit 1. Healthy Families Arizona Program Sites in State Fiscal Year 2015 Site Cochise County / Santa Cruz County Coconino County Coconino County / Navajo County Graham County / Greenlee County Maricopa County Mohave County Mohave County / La Paz County Pima County Pinal County Verde Valley (in Yavapai County) Yavapai County Yuma County Statewide Healthy Families Arizona Annual Evaluation Report 2015 Number of Teams 2 1 3 2 16 2 2 6 3 1 1 2 41 9 In This Report The purpose of this report is to provide information on families’ outcomes, program performance measures, process and implementation information, and evaluation information that can be used to guide program improvement. This report covers the state Fiscal Year 2015 from July 1, 2014 to June 30, 2015. Additionally, this report also reviews recently published literature related to Healthy Families and home visitation program. The evaluation of Healthy Families Arizona includes both process and outcome evaluation. The process evaluation includes an update of statewide implementation, describes the characteristics of families participating in the program, and provides general satisfaction of families participating in the program. The outcome evaluation examines program outcomes and looks at the program’s impact across a number of measures, with comparisons to previous years when appropriate and available. Detailed appendices provide specific site data on process and outcome variables. The description of evaluation methodology outlines the methods used for each part of the report. The 2015 Annual Evaluation Report has been designed to provide vital information and reporting of yearly data for basic accountability and credentialing. The data analyzed are limited to only those families within 24 months of the birth of the infant. Currently, the Healthy Families Arizona evaluation also includes the creation and distribution of quarterly cumulative performance reports for ongoing program monitoring. These reports are used during quality assurance and technical assistance site visits to review and assess progress on key program activities, including administration rates for developmental screenings and parenting skills inventories, attainment of immunization data, and substance abuse screening. Evaluation Methodology The Healthy Families Arizona evaluation includes both a process evaluation component and an outcome evaluation component. The primary questions for the process evaluation include: Who participates in the program and what are the services provided? The primary question for the outcome evaluation is: What are the short and long term outcomes for families in the program? Healthy Families Arizona Annual Evaluation Report 2015 10 In order to answer the process evaluation question, participants of the Healthy Families Arizona program are described and the services they receive are documented. In the process evaluation, the program “inputs” such as numbers served, participant characteristics, and services received are described. Also, information relative to Critical Elements and expected standards from Healthy Families America is provided as a benchmark for assessing some aspects of the implementation. The primary data for the process evaluation comes from the management information system developed to process data for Healthy Families Arizona. Sites are required to submit data that captures enrollment statistics, number of home visits, administration of assessment and outcome forms, descriptions of program participants, types of services provided, and other relevant information. The overall aim for the outcome study is to examine program effects and outputs, at both the parent and child level on a number of different outcomes. During the course of the evaluation, the evaluation team has worked together with program staff to develop and select key program measures that are used to provide feedback and to measure the program’s ability to achieve specific outcomes. The primary activities of the outcome evaluation are to: examine the extent to which the program is achieving its overarching goals, examine the program’s effect on short term goals, and examine the extent to which participant characteristics, program characteristics, or community characteristics moderate the attainment of the program’s outcomes. For most of the outcome measures, Healthy Families home visitors collect baseline (pretest) data and follow-up data at different time points of program participation: 6 months, 12 months, 18 months, and 24 months. The outcome evaluation also includes examination of substantiated cases of child abuse and neglect obtained through the Department of Economic Security’s CHILDS database. The process and outcome components of the evaluation were developed and guided by the logic models for both the prenatal and postnatal programs. Logic models for the prenatal and postnatal components of Healthy Families Arizona are presented in the Appendices. Healthy Families Arizona Annual Evaluation Report 2015 11 Review of Current Literature According to the most recent Child Maltreatment report conducted by U.S. Department of Health and Human Services, there were 679,000 substantiated reports of child maltreatment in 2013 (U.S. Department of Health and Human Services, 2015). Due to the high prevalence and associated costs of child maltreatment, policy makers, program developers, and various stakeholders have vested interest in finding ways to support overburdened families susceptible to adverse childhood experiences. Home visitation programs are designed to be a preventative and cost-saving measure in place to support the healthy development of children while reducing issues often encountered by low-income families. Home visitation programs provide assessment, parent education and support, and referral to and coordination with services needed by children and their families. Methods to provide these supports include setting goals with caregivers and determining strategies to meet their goals, assisting caregivers with issues negatively impacting their families, teaching problem-solving skills and parenting skills, assisting parents and children with conflict resolution and crisis intervention, providing education to caregivers about their child’s development, strengthening support networks, and coordinating referrals to community resources. High priority outcomes that are commonly shared by home visitation programs include promoting positive parenting behavior, increasing the utilization of prenatal care, improving parent-child interaction and school readiness, preventing child abuse and neglect, fostering economic BENEFITS OF HEALTHY FAMILIES Studies of various Healthy Families programs (including New York, Massachusetts, Arizona, and in American Indian communities) show that participants benefit in many ways, including: • Reduced abusive and neglectful parenting practices • Reduced risk of low birth weight • Improvements on measures of harsh discipline • Increased parent knowledge • Increased maternal involvement • Decreased parenting stress • Increased use of safety practices • Improved parenting attitudes • Parents reading more often with their children • Increased access to resources • Reduced alcohol use • Increased schooling and training for parents self-sufficiency, encouraging child preventive care and increasing access to primary care medical services, and promoting child development. Healthy Families Arizona Annual Evaluation Report 2015 12 Recent studies have shown that some home visiting programs have reduced the occurrence of child maltreatment. Home visitation programs continue to attract researchers and evaluators in an effort to determine how to build more effective practice models. As the federal government has invested over $1.5 billion into home visitation programs in states, territories and tribal entities over the last five years and recently approved an additional two-year $800 million investment into The Maternal, Infant, and Early Childhood Home Visiting Program, it is critical that there is a continued effort to document and track home visiting program outcomes (Prevent Child Abuse America, 2013). The Home Visiting Evidence of Effectiveness review for the U.S. Department of Health and Human Services found 14 home-visiting programs that have undergone at least one highquality or moderate-quality evaluative study with at least two favorable, statistically significant impacts in the same domain or two different domains. The outcome measures in the comprehensive review were in the domains of Child Health, Maternal Health, Child Development and School Readiness, Reductions in Child Maltreatment, Reductions in Juvenile Delinquency, Family Violence, and Crime, Positive Parenting Practices, Family Economic Self-Sufficiency Linkages and Referrals (Avellar, 2013). The most common themes among favorable outcomes were related to child development, school readiness and positive parenting practices. Healthy Families America had the most favorable impacts in both primary and secondary measures (Avellar, 2013). The programs identified as being evidence-based in the study, listed alphabetically are: • Child FIRST • Early Head Start-Home Visiting • Early Intervention Program for Adolescent Mothers (EIP) • Early Start (New Zealand) • Family Check-Up • Healthy Families America (HFA) • Healthy Steps • Home Instruction for Parents of Preschool Youngsters (HIPPY) • Maternal Early Childhood Sustained Home Visiting Program • Nurse Family Partnership (NFP) • Oklahoma’s Community-Based Family Resource and Support (CBFRS) Program • Parents as Teachers (PAT) • Play and Learning Strategies (PALS) Infant • SafeCare Augmented. Healthy Families Arizona Annual Evaluation Report 2015 13 Recent research has shown that collaborative home visitation programs have better outcomes than non-collaborative home visitation programs. Haynes et al. (2015) found that parents who received collaborative home visitation services were statistically more likely to see progression in relationships with family and friends, education, employment, health and medical care, mental health and substance abuse and other basic needs when compared to parents receiving services through a non-collaborative program. Recently there has been emphasis in home visitation research on framing childhood adversity and life-course trajectories in the context of psychological stress and associated health outcomes (Garner, 2015). Childhood adversity has been linked to poor health outcomes such as depression, substance abuse, teenage pregnancy, obesity, type II diabetes, and cardiovascular disease (Anda et al., 2006). In this context, researchers have examined the potential link between collaborative home visitation models that include teams of pediatricians, early educators, early intervention and home visitation specialists and the ability of caregivers to increase skills for future learning, behavior, and health (Garner, 2015). Federal funding continues to support evaluative research on the effectiveness of home visitation programs. The Patient Protection and Affordable Care Act and The Protecting Access to Medicare Act of 2014 provided funding for The Mother and Infant Home Visiting Program Evaluation (MIHOPE); a legislatively mandated, large-scale evaluation of the effectiveness of the home visitation program Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). In 2015, MIHOPE will study four evidence-based national program models all serving families at risk of poor child outcomes: Early Head Start, Home Based Program Option, Healthy Families America, Nurse-Family Partnership, and Parents as Teachers (Michalopoulos et al., 2015). The study will include an analysis of the needs assessment, analysis on the effects on the healthcare system, an effectiveness study and subgroup analysis. In their 2015 report to Congress on the evaluation plan and early findings, MIHOPE stated that they plan to enroll over 4,000 families in 88 different home visitation programs in 12 states (California, Georgia, Illinois, Iowa, Kansas, Michigan, Nevada, New Jersey, Pennsylvania, South Carolina, Washington, and Wisconsin) operating in one of the four national models to review effects on a range of identified outcomes. Each of the 12 states have submitted plans for how they believe federal dollars should be spent based on high priority needs within their state (Michalopoulos et al., 2015). MIHOPE has compiled information from interviews with developers of the four national models and web-based surveys completed by 77 program managers and 377 home visitors in order to determine strengths and limitations in current program protocols. Some common themes among program strengths were that nearly all local programs required Healthy Families Arizona Annual Evaluation Report 2015 14 formal screenings and assessments to identify maternal mental health issues, infant developmental delays, maternal substance abuse, intimate partner violence, and parenting behavior. Most national program developers and survey respondents from local home visitation programs reported their program protocols included helping families’ access necessary resources (Michalopoulos et al., 2015). The MIHOPE early findings report also indicated that all four national models encouraged home visitors to observe parent-child interactions, provide feedback and to use supportive strategies such as goal setting, problem solving, or emotional support. Some common themes among limitations in programs were many local programs did not have a formal protocol in place for when issues were detected through screening tools. Although most local programs across all national models reported that they encouraged home visitors to demonstrate positive parenting practices, not all national models encouraged home visitation programs to demonstrate these skills (Michalopoulos et al., 2015). Although there has been a significant increase in home visitation research in the past ten years, there is limited original research on home visitation program effectiveness from 2013 to present. However, the large-scale, national-wide Mother and Infant Home Visiting Program Evaluation shows promise in substantially furthering research on home visitation effectiveness. Home visitation programs continue to develop and target varying and complex needs of overburdened families susceptible to adverse childhood experiences. Healthy Families Arizona Annual Evaluation Report 2015 15 Program Updates Training and Professional Development Throughout the state fiscal year 2015, Healthy Families Arizona staff participated in a variety of professional development opportunities. • On July 17-18, 2014, DCS Central Administration and HFAz staff from different program levels attended the Twentieth Arizona Child Abuse Prevention Conference presented by Prevent Child Abuse Arizona in Glendale, AZ. The conference included workshops that cover a variety of prevention related topics, special selections for supervisors and administrators, resource/informational booths that included services to support families, and opportunities for networking with other home visiting professionals. • On September 9-10, 2014, DCS Central Administration staff and several program Supervisors, Family Assessment Workers, and Family Support Specialists participated in the Third Annual Strong Families Arizona Home Visitors Conference in Glendale, AZ. The conference was sponsored by the U.S. Department of Health and Human Services through the MIECHV grant. The conference provided attendees with a variety of home visiting related topics in the areas of prevention and intervention. • On March 19-21, 2015, DCS Central Administration and five HFAz staff from different regions of the state attended the National Conference on Health and Domestic Violence in Washington, DC. The conference featured three full days of workshops and presentations aimed to advance the health care system’s response to domestic violence. • On May 7-8, 2015, DCS Central Administration staff and four Program Supervisors participated on the Fifth National Summit on Quality in Home Visiting Programs in Washington, DC. The conference offered a forum to learn about the latest developments in the field and address strategies to building high-quality, sustainable early childhood systems. • On June 10-11, 2015, DCS Central Administration staff and four Program Supervisors attended the 2015 Children’s Bureau Formula Grantee Meeting in Washington, DC. The meeting included several grant clusters that provided federal updates and information, expert presentations, and opportunities for peer sharing. Healthy Families Arizona Annual Evaluation Report 2015 16 MIECHV Grant During state fiscal year 2015, DCS Central Administration collaborated with the AZ Department of Health Services for the development and integration of the Social Solutions, ETO Database project. The staff at HFAz and Program level worked through the initial phases of the ETO database development. These initial phases included comprehensive review of existing forms, determination of adjustments to meet program requirements related to contract stipulations, HFAz policy and procedures, and national accreditation. Quality Assurance and Training Assistance During the state fiscal year 2015, the Quality Assurance and Training Assistance (QA/TA) team experienced significant staff shortage. Despite the limited staff resources, CA maintained continuation of quality assurance and technical assistance to all sites including completion of annual site visits, technical assistance, oversee of various program administrative components, and initiated preparation for the next HFAz reaccreditation process. The DCS, Central Administration Manager continues efforts to bring the QA/TA team to full staff capacity. The DCS Central Administration led organization of HFAz reaccreditation preparation including development of timeline, tools, design and structure of in-state pre-accreditation site visits, and coordination of general logistics with Healthy Families America accreditation application process. Program sites were provided with technical support as they prepared their accreditation self-study and gathered the required program implementation documentation. The DCS Central Administration coordinated all planning and execution logistics to bring the Partners for a Healthy Baby curriculum materials and training to Arizona. On October 28-30, 2014 HFAz staff completed the Partners for a Healthy Baby Curriculum to meet the Healthy Families America accreditation requirement of using evidence-informed curriculum in the work with families. Training was provided to 60 staff from the following sites: Lake Havasu, Coconino, Tuba City, Winslow, Verde Valley, Maricopa, Pima, Cochise, and Yuma. Additionally, 18 of the 60 staff were trained to become their site trainers using a modified version of the Train-the-Trainer model. The Partners for Healthy Baby Curriculum is designed to cultivate and promote nurturing parent-child relationships, healthy child development, parenting skills, and includes activities for preventive health and safety. Healthy Families Arizona Annual Evaluation Report 2015 17 Collaboration between First Things First and Arizona Department of Health Services DCS Central Administration continues being the hub for the coordination and collaborative efforts with First Things Firsts (FTF) and the Arizona Department of Health Services (ADHS). DCS Central Administration focuses on maintaining healthy working relationships with FTF and ADHS to support model fidelity and consistency across program's statewide evaluation, training, quality assurance, technical assistance, program development, administration, and any other program related activity. Healthy Families Arizona Annual Evaluation Report 2015 18 Healthy Families Arizona Participant Characteristics Data were submitted for a total of 4,911 families for evaluation purposes during the current study year from July 1, 2014 through June 30, 2015. A total of 2,047 were funded through the Department of Child Safety; 1,392 through First Things First; and 1,472 through MIECHV. The evaluation of the statewide Healthy Families Arizona system includes only families with children that are 24 months old or younger (n=4,191). The remaining 720 families’ children were between 24 and 60 months, so were not included in the evaluation. In order to have a meaningful evaluation of the program effects only the families that receive at least a minimal amount of program exposure are included. This means, that families need to have been in the program long enough to commit to participating and received some curriculum from the home visitors. Four home visits was decided to be the minimum amount of program exposure for inclusion in the evaluation. This further restricts the dataset to include only those families with full data showing that they have received at least four home visits. A total of 3,445 families are included in this report. Thus, the data for this report focuses on families who were within the first 24 months after the birth of the infant and “actively engaged” (received four or more home visits) in the Healthy Families program regardless of when they entered the program. Just under a quarter (23.2%) of the families enter the program in the prenatal period (prenatal participants) and about three quarters (76.8%) of the families enter the program after the birth of the child (postnatal participants). For the July 2014 to June 2015 evaluation cohort, there were 798 prenatal and 2,647 postnatal families. Exhibit 2 presents the total numbers of prenatal and postnatal families actively engaged from July 2014 to June 2015. Healthy Families Arizona Annual Evaluation Report 2015 Image courtesy of www.jachip.org 19 Exhibit 2. Participants Included in the Evaluation for State Fiscal Year 2015 County Cochise Coconino Graham/ Greenlee Maricopa Mohave Mohave/La Paz Navajo Pima Pinal Santa Cruz Yavapai Yuma Site Team # 12 Team # 18 Team # 13 Team # 90 Team # 28 Team # 92 Team # 2 Team # 3 Team # 5 Team # 19 Team # 23 Team # 48 Team # 61 Team # 62 Team # 64 Team # 65 Team # 68 Team # 80 Team # 83 Team # 84 Team # 88 Team # 89 Team # 33 Team # 43 Team # 17 Team # 91 Team # 32 Team # 8 Team # 9 Team # 10 Team # 11 Team # 27 Team # 81 Team # 82 Team # 85 Team # 86 Team # 6 Team # 21 Team # 87 Team # 15 Team # 70 Total Healthy Families Arizona Annual Evaluation Report 2015 Prenatal Postnatal Total 15 31 29 8 31 7 12 11 24 28 28 15 9 20 30 15 22 26 31 24 13 15 47 28 31 5 19 14 17 16 10 17 20 17 16 9 28 13 17 16 14 798 60 37 43 17 54 11 59 68 73 91 86 83 56 70 86 85 50 95 99 99 106 84 35 42 65 20 39 73 87 52 44 84 76 59 48 74 83 81 31 63 79 2,647 75 68 72 25 85 18 71 79 97 119 114 98 65 90 116 100 72 121 130 123 119 99 82 70 96 25 58 87 104 68 54 101 96 76 64 83 111 94 48 79 93 3,445 20 Length of Time in Program and Reasons for Termination Healthy Families America in their HFA Best Practice Standards recommends that services are offered until the child is a minimum of three years old and up to age five. In State Fiscal Year 2015, a total of 1,342 of the 3,445 families in the evaluation sample closed during the year. Of the 3,445 families served, 1,341 enrolled during fiscal year 2015. For the newly enrolled families, 421 closed (31.4%), for a retention rate of 68.6%. The length of time in the program for families that closed in fiscal year 2015 is slightly higher than last year, but similar to prior years (Exhibit 3). For all families (N=1,342) who closed in State Fiscal Year 2015: • The median number of days in the program was 281 days (as compared to 246 in 2014, 263 in 2013, and 290 in 2012); • The average length of time in the program was 345 days (as compared to 320 in 2014, 346 in 2013, and 352 in 2012); and • Thirty-seven percent of families were in the program one year or longer (as compared to 33% in 2014, 37% in 2013, and 38% in 2012). Exhibit 3. Length of Time to Closure in Days for State Fiscal Years 2012 to 2015 400 380 Number of Days 360 340 320 300 280 260 240 220 200 2012 2013 Median Healthy Families Arizona Annual Evaluation Report 2015 2014 2015 Average 21 Exhibit 4 shows the distribution of length of time that families stayed in the program for all families who closed in 2015. The largest percentage of families (36%) who closed in 2015 were in the program between 6 and 12 months. Exhibit 4. Families’ Length of Time to Closure for State Fiscal Year 2015 36% 19% 18% 11% 9% Less than 3 months 8% 3 to less than 6 to less than 12 to less than 18 to less than 24 months or 6 months 12 months 18 months 24 months more Exhibit 5 shows the most frequent reasons families left the program during this year. The most common reason a family’s case was closed was due to the family moving away for prenatal families, and refusing further services for postnatal families. A breakout by site is presented in Appendix A. Exhibit 5. Most Frequent Reasons for Termination State Fiscal Year 2015 Reason Moved away Did not respond to outreach efforts Family refused further services Self-sufficiency Prenatal Postnatal Overall 24.5% 17.9% 16.0% 11.9% 17.8% 19.2% 19.6% 15.6% 19.4% 18.9% 18.7% 14.7% Healthy Families Arizona Annual Evaluation Report 2015 22 Maternal Risk Factors Upon enrollment into Healthy Families Arizona, both prenatal and postnatal mothers have certain risk factors that are higher than the average rates for all mothers in the State of Arizona. The percentage of Healthy Families Arizona mothers who are teenagers is moderately lower than last year. In 2015, 18.5% of prenatal mothers and 14.1% of postnatal mothers enrolled are teens compared to 20.9% and 16.4%, respectively, in 2014. The majority of all mothers are single (71.7%) at enrollment, with only 28.3% of mothers married at enrollment. Mothers enrolled in Healthy Families Arizona are twice as likely to have less than a high school education (35.7%) compared to all mothers in the State (19.7%). More than three quarters (77.0%) of Healthy Families Arizona mothers are unemployed and 83.3% are receiving AHCCCS at enrollment. The median income of the enrolled mothers is below the 2015 Federal Poverty Level ($15,930 for a family of 2), indicating that many participants are living in poverty. In relation to the state and national rates, these data confirm that Healthy Families Arizona participants do represent an “at-risk” group of mothers and that the program has been successful in recruiting families with multiple risk factors associated with child abuse and neglect and poor child health and developmental outcomes. Exhibit 6 presents selected risk factors for both prenatal and postnatal mothers at intake compared with state rates. Exhibit 6. Selected Risk Factors for Mothers at Intake State Fiscal Year 2015 Prenatal Postnatal Risk Factors of Mothers Families Families Teen Births (19 years or less) 18.5% 14.1% Births to Single Parents 71.4% 71.8% Less Than High School Education 35.5% 35.8% 73.6% 78.1% Not Employed 4.4% 6.1% No Health Insurance 88.0% 81.9% Receives AHCCCS Late or No Prenatal Care 27.1% 35.6% Median Yearly Income $10,800 $12,000 Arizona state Rates 8.5%* 45.1%* 17.6%* 45.8%** 3.6%* 53.8%* 18.7%* $50,068 ** Percent does not include “unknown.” Source: Prenatal and Postnatal Families data from the Healthy Families Arizona FY 2015 data *2013 data from the Arizona Department of Health Services Vital Statistics records. **U.S. Census Bureau, American Community Survey, 2013 Note: Percentages for the combined total for prenatal and postnatal families can be found in Appendix A. “My FSS makes me feel like I am doing a good job as a single mom – Mohave County Healthy Families Arizona Annual Evaluation Report 2015 23 Infant Characteristics In addition to mother risk factors, information about infant risk factors is collected at intake for postnatal families and at birth for prenatal families. This information gives an indication of the level of need of the families served by the program. The overall risk factors for infants in 2015 are similar to prior years. The percentage of postnatal Healthy Families Arizona program infants born early (less than 37 weeks gestation) remains higher than the overall state rate, suggesting that the families being identified for service have a significant level of need. The percentage of low birth weight infants in the program and positive alcohol/drug screening postnatal also remains high in comparison to the state rate. Exhibit 7 below shows the prenatal, postnatal, and Arizona State rates for a set of infant characteristics that are considered in the field to be risk factors for child maltreatment. Exhibit 7. Risk Factors for Infants - State Fiscal Year 2015 Prenatal* 9.7% Born <37 Weeks Gestation 16.0% 9.0%*** Postnatal** Arizona State Rate 1.1% 0.8% 0.7%*** Birth Defects 8.2% Low Birth Weight 13.5% 6.9%*** 1.6% Positive Alcohol/Drug Screen 1.6%*** 0% 5% 10.2% 10% 15% 20% *The Family Support Specialist collects this information either from the family or from a DCS referral form for prenatal families. **Family Assessment Workers collect this information from hospital records for postnatal families. *** 2013 data from the Arizona Department of Health Services Vital Statistics records. Healthy Families Arizona Annual Evaluation Report 2015 24 Race and Ethnicity The Healthy Families Arizona program serves a culturally diverse population. In the following exhibits, ethnicity and race are examined for all mothers and fathers based on information gathered at enrollment. Fifty-five percent of the mothers and 55.8% of the fathers enrolled in the program are Hispanic (see Exhibit 8). Exhibits 9 and 10 display mothers’ and fathers’ race. Site level data for race and ethnicity are available in Appendix A. Exhibit 8. Parent’s Ethnicity State Fiscal Year 2015 100% 80% 60% 40% 20% 0% NonHispanic, 45.0% NonHispanic, 44.2% Hispanic, 55.0% Hispanic, 55.8% Mothers Fathers Exhibit 9. Mother’s Race* State Fiscal Year 2015 African American 6.0% Native American 7.5% Other/Mixed 9.5% Asian American 1.2% White/Caucasian 75.8% *This includes all mothers who entered the program either prenatally or postnatally. Healthy Families Arizona Annual Evaluation Report 2015 25 Exhibit 10. Father’s Race* State Fiscal Year 2015 African American 6.7% Native American 6.3% Other/Mixed 10.8% Asian American 1.0% White/Caucasian 75.2% *This includes all fathers who entered the program either prenatally or postnatally. Assessment of Risk Factors Both mothers and fathers are assessed at intake using an interview with the Parent Survey 1. The Parent Survey helps the program learn about the family’s circumstances and life events that place them at risk for child maltreatment and other adverse outcomes. During the intake process, the Family Assessment Worker evaluates each family across the 10 domains of the Parent Survey. The survey is administered in an interview format and the items are then rated by the worker according to level of severity. The percentage of parents scoring severe on each of the scales is presented for prenatal mothers and fathers and for postnatal mothers and fathers in Exhibits 11 and 12. “Being new parents and no other relatives to support us, it is very assuring that there are people who can guide us as parents and help our family become more cohesive.” – Pima County Previously known as The Family Stress Checklist, it was renamed the Parent Survey based on revisions to focus on a more strength based perspective; however, the rating scale remains unchanged. More information on this instrument is provided in Appendix C. 1 Healthy Families Arizona Annual Evaluation Report 2015 26 Exhibit 11. Percentage of Parents Rated Severe on Parent Survey Items PRENATAL Parental Attachment Mother Difficult Child Father Discipline Attitudes Expectations of Infant Violence Potential Current Life Stresses Social Support, Isolation CPS Involvement Crime, Substance Abuse, Mental… Parent Childhood Abuse 0 10 20 30 40 50 60 70 80 90 100 70 80 90 100 Exhibit 12. Percentage of Parents Rated Severe on Parent Survey Items POSTNATAL Parental Attachment Mother Father Difficult Child Discipline Attitudes Expectations of Infant Violence Potential Current Life Stresses Social Support, Isolation CPS Involvement Crime, Substance Abuse,… Parent Childhood Abuse 0 10 20 Healthy Families Arizona Annual Evaluation Report 2015 30 40 50 60 27 The four factors rated most severe by both mothers and fathers remain consistent with previous years’ data. These include: history of childhood abuse (for the parent); current life stressors; social support and isolation; and a history of crime, substance abuse, or mental illness. A higher percentage of prenatal mothers had severe scores on history of childhood abuse (77.8%) and current life stresses (72.2%) than postnatal mothers at 70.9% and 66.7%, respectively. Summary The process evaluation for fiscal year 2015 suggests that the Healthy Families Arizona program continues to effectively reach parents and infants with high risks for child maltreatment and other unhealthy outcomes. The population that Healthy Families Arizona is serving has greater risks than the state or national population as a whole. Overall, the Healthy Families Arizona program is reaching families that are impoverished, stressed, socially disadvantaged, and lacking in resources to manage the demands of parenting. Families that enter during the prenatal period have slightly higher risks than families that enter after birth. However, the risk factors of low birth weight babies, preterm birth, and substance exposed newborns are lower for those families participating in Healthy Families Arizona prenatally than for those that enter in the postnatal period. This suggests that these high risk families benefit from the early support that is offered in the home visitation program. “When this family initially entered the Healthy Families program three years ago, there were a variety of high risk factors that could have negatively impacted the children’s development and the parent child relationship. Mom was sporadically employed and housing was unstable. She and her three sons drifted from house to house depending on the generosity of friends, families and acquaintances. Dad and mom had a history of domestic violence. Both parents had a substance abuse history. Developmental screens on the older children reflected delays in their language and social skills. The FSS advocated for school district early intervention and mom agreed. Both boys were eligible for services and the FSS helped mom enroll them in developmental preschool. In the past few months, mom has been acknowledging her efforts to provide for her children in a variety of ways. She has had stable housing and employment for over a year, the children are thriving in preschool and day care and she has made time in her busy life to read to them every night. She has kept AHCCCS updated and all her children’s immunizations and well checks are currentsomething that had been lacking three years ago. With this new found confidence, she is exploring the idea of self-sufficiency and independence for herself.” – Maricopa County Healthy Families Arizona Annual Evaluation Report 2015 28 Key Healthy Families Arizona Services The primary goals of reducing child abuse and neglect and improving child well-being are only attainable when families stay engaged in the program and receive the services and supports they need. One important aspect of the Healthy Families program model is linking families with needed community resources. Home visitors provide not only assistance and guidance in the home, but they also connect families with education, employment, and training resources, counseling and support services, public assistance, and health care services. Developmental Screens and Referrals for Children Developmental screens are used to measure a child’s developmental progress and to identify potential developmental delays requiring specialist intervention. The primary screening tool used by home visitors is the Ages and Stages Questionnaire, Third Edition (ASQ-3). This tool helps parents assess the developmental status of their child across five areas: communication, gross motor, fine motor, problem solving, and personal-social. The Healthy Families Arizona program administers the ASQ-3 at 4, 6, 9, and 12 months in the first year of the infant’s life, every six months until the child is three years of age, and then yearly at age 4 and 5. As Exhibit 13 shows, the number of children receiving the ASQ-3 at each interval is exceeding 90% in the time periods up to 12 months. Both 18-month and 24-month ASQ-3 rates fell just short of the statewide performance goals this year. The 18month ASQ-3 rate decreased to 86.7% from 91.5% in 2014 while the 24-month ASQ-3 rate fell to 84.7% from 84.9% last year. Similar rates of children were identified as delayed as in the prior year for the 4-month to 18-month screenings. However, an increase from 8.3% in 2014 to 11.3% in 2015 in the percentage of children identified as delayed at 24-months should be further examined by program staff. Exhibit 13. ASQ-3 Screening State Fiscal Year 2015 Interval Percent of children ASQ-3 Screening Screened with ASQ-3 4-month 96.4% 6-month 94.8% 9-month 97.5% 12-month 92.7% 18-month 86.7% 24-month 84.7% Healthy Families Arizona Annual Evaluation Report 2015 Percent screened as delayed 2.3% 2.2% 4.5% 4.9% 6.4% 11.3% 29 Healthy Families Arizona works to ensure that children who may have developmental delays obtain needed interventions. Program data tracks what happens after a family’s ASQ-3 is scored as follows: 1) the child is screened as having no delays, 2) the child is referred for further assessment and is determined to have no delays upon a more extensive assessment, 3) families are referred to different services such as the Arizona Early Intervention Program (AzEIP) or other early intervention or therapy, or 4) the home visitor may provide developmental intervention or education to the family. Although approximately 2% to 11% of children (depending on their age) are initially screened as delayed in their development, up to 7.0% of the children who initially screen as delayed on the ASQ-3 in the early months of their life are determined to not have delays upon further assessment (see Exhibit 14 below). This is a common occurrence, as children develop at different speeds in the early months of life. However, some children continue to show delays for which early access to services can be provided. The ASQ-3 screening provides a valuable service to families because it enables them to access appropriate services to meet their child’s particular needs. This practice is consistent with the American Academy of Pediatrics strategic plan to promote developmental screening and establish a medical home when needed (Tait, 2009). There is a national effort to increase early developmental screening after studies found that up to 70% of developmental problems were not identified until school entry (e.g., see Glascoe & Dworkin, 1993). The following exhibit shows the outcome of these follow-up assessments that are completed with families at the different time intervals. Exhibit 14. ASQ-3 Follow-up Services State Fiscal Year 2015 Continued Referred Referred to Provided Assessment Screening to other Early Developmental shows Interval AzEIP Intervention Intervention “no delay” % (n) % (n) % (n) % (n) 7.0% (4) 31.6% (18) 3.5% (2) 78.9% (45) 4-month 2.0% (1) 37.3% (19) 5.9% (3) 76.5% (39) 6-month 4.1% (3) 31.5% (23) 2.7% (2) 78.1% (57) 9-month 5.6% (4) 35.2% (25) 2.8% (2) 64.8% (46) 12-month 1.8% (1) 28.1% (16) 8.8% (5) 64.3% (36) 18-month 4.1% (2) 38.8% (19) 12.2% (6) 61.2% (30) 24-month Referred to Therapy % (n) Parent Declined Referral % (n) 7.0% (4) 3.9% (2) 1.4% (1) 5.6% (4) 8.9% (5) 4.1% (2) 15.8% (9) 19.6% (10) 24.7% (18) 22.9% (16) 21.4% (12) 20.4% (10) Note: Percentages do not equal 100% as multiple referrals can happen for a single child. Healthy Families Arizona Annual Evaluation Report 2015 30 Outcomes for Families The Healthy Families Arizona program focuses the outcomes evaluation on the following primary indicators: • Parent outcomes • Child development and wellness • Mother’s health, education, and employment • Child abuse and neglect Parent outcomes One of the primary intermediate goals of the Healthy Families Arizona program is to have a positive influence on parenting attitudes and behaviors. While reducing child abuse and neglect is the ultimate outcome, intermediate objectives, such as changes in parenting behaviors, can inform us about progress toward the ultimate goal. The intermediate goals of the Healthy Families program revolve around a few key factors known to be critical in protecting children from maltreatment (Jacobs, 2005): • providing support for the family; • having a positive influence on parent-child interactions; • improving parenting skills and abilities and sense of confidence; and • promoting the parents’ healthy functioning. Research from a randomized clinical trial of the Healthy Families Arizona program (LeCroy & Krysik, 2011) supports the finding that the program can produce positive change favoring the experimental group in contrast to the control group across multiple outcome domains such as parenting support, parenting attitudes and practices, violent parenting behavior, mental health and coping, and maternal outcomes. Healthy Families Parenting Inventory Reveals Positive Parent Change In order to better evaluate critical goals of the Healthy Families program, the evaluation team developed the Healthy Families Parenting Inventory (HFPI) in 2004 (LeCroy, Krysik, & Milligan, 2007). This instrument was developed, in part, because of measurement difficulties identified in the literature (See LeCroy & Krysik, 2010). The development of the HFPI was guided by several perspectives and sources: the experience of the home visitors in the Healthy Families Arizona program; data gathered directly from home visitors, supervisors, and experts; information obtained from previous studies of the Healthy Families program; and examination of other similar measures. The process included focus groups with home visitors, the development of a logic model, and a review of relevant Healthy Families Arizona Annual Evaluation Report 2015 31 literature. In an initial validation study the pattern of inter-item and item-to-subscale correlations, as well as an exploratory factor analysis and sensitivity to change analysis, supported the nine-factor model of the HFPI. This work was published in the journal Infant Mental Health (Krysik & LeCroy, 2012). The final instrument includes 9 scales: Social Support, Problem-solving, Depression, Personal Care, Mobilizing Resources, Role Satisfaction, Parent/Child Interaction, Home Environment and Parenting Efficacy. The following section describes the results obtained for each subscale of the HFPI. The level of significance is reported along with the effect size. An effect size gives a sense of how large the change or improvement is from baseline to 6 months or 12 months. Effect sizes below 0.20 are considered small changes, and those between 0.20 and 0.50 are considered small to medium changes. These findings are based on data reported from the sites and represent participants who completed both instruments at the baseline and 6 month intervals (n=2442) and participants who also had matched instruments at the 12 month interval (n=1760). Paired t-tests were used for each subscale. Healthy Families Parent Inventory (HFPI) Subscales Exhibit 15. Change in Subscales of the HFPI Significant improvement Sub- scale from baseline Significance to 6 months Effect size Significant improvement from baseline to 12 months Significance Effect size Social Support Problemsolving Depression  .007 (0.05) None .380 (0.02)  .000 (0.17)  .000 (0.21)  .000 (0.09)  .000 (0.13) Personal care Mobilizing resources Commitment To Parent Role Parent/Child Behavior Home Environment Parenting Efficacy  .000 (0.17)  .000 (0.17)  .000 (0.32)  .000 (0.39)  .000 (0.12)  .000 (0.15)  .000 (0.26)  .000 (0.20)  .000 (0.39)  .000 (0.48)  .000 (0.18)  .000 (0.15) From baseline to 6 months, there were statistically significant changes in all subscales. From baseline to 12 months the statistical significance in the Social Support subscale was lost, while all others remained significant. The largest improvements (as shown by the effect Healthy Families Arizona Annual Evaluation Report 2015 32 sizes) at 6 months after entering the program are in the categories of home environment (0.39), mobilizing resources (0.32), and parent/child behavior (0.26) scales. At 12 months the largest improvements are in home environment (0.48), mobilizing resources (0.39), problem solving (0.21), and parent/child behavior (0.20). This indicates that the Healthy Families Arizona sites are effective at connecting parents to resources, improving the atmosphere of the home, improving parents’ problem solving skills, and improving the interaction between parents and children. Total Change Score on the HFPI In order to provide a more comprehensive understanding of outcomes in parenting observed during participation in the Healthy Families program, it is also useful to examine the total score on the Healthy Families Parenting Inventory and overall significance of change. As Exhibit 16 below shows, there were significant changes from baseline to 6 months and from baseline to 12 months on the HFPI total scale. This finding supports the conclusion that program participants showed positive changes during the course of the program. Overall, approximately 65% of parents had positive changes on the total score from baseline to 6 months (65.3%) and from baseline to 12 months (65.6%). Exhibit 16. Overall Change in Healthy Families Parenting Inventory Outcomes Significant Significant Subimprovement Effect improvement Significance Significance scale from baseline size from baseline to 6 months to 12 months Total .000 (0.31) .000   Scale Effect size (0.32) Child Abuse and Neglect One of the main goals of Healthy Families Arizona is to reduce the incidence of child maltreatment and abuse. In order to look at child abuse and neglect directly, data from CHILDS, the Arizona Department of Child Safety data system is used to determine the rates of child abuse and neglect for Healthy Families Arizona participants. It is important to acknowledge that using official child abuse data as an indicator of program success is complex and is unlikely to fully answer the question about the effectiveness of Healthy Families Arizona in preventing child abuse. The shortcomings in using official child abuse rates to assess the effectiveness of home visiting programs have been discussed in numerous journal articles (see for example, The Future of Children, 2009). There are several reasons the use of child abuse data is believed to have limitations. First, child abuse is an event that occurs infrequently and, therefore, changes are difficult to detect with statistical methods. Second, using official incidents of child abuse and neglect does not necessarily reflect actual behavior—there are many variations in what constitutes Healthy Families Arizona Annual Evaluation Report 2015 33 abuse and neglect and using only reported and substantiated incidents of abuse captures incidents that rise to that level of severity. Some incidents of child abuse or neglect are undetected or may not meet some definitional standard minimizing the accuracy of the count. Third, using official data requires a process whereby cases are “matched” on available information such as mother’s name, social security number, and date of child’s birth. When any of this information is missing, the accuracy of the match decreases. Finally, because home visitors are trained in the warning signs of abuse and neglect and are required to report abuse or neglect when it is observed, there is a “surveillance” effect— what might have gone unreported had there been no home visitor shows up in the official data. In order to best represent families that have received a significant impact from the Healthy Families Arizona program, only families that have been in the program for at least six months are analyzed to determine if they have a substantiated report of child abuse or neglect. This year, 95.7% of the Healthy Families Arizona eligible families (2,544 out of 2,658) were without a substantiated report, as can be seen in Exhibit 17. A total of 114 cases were determined to be substantiated reports. A substantiated finding means that “the Department of Child Safety has concluded that the evidence supports that an incident of abuse or neglect occurred based upon a probable cause standard” (see DCS substantiation guidelines for further detail). The increase in substantiated cases this year may be due to the additional efforts to investigate all open cases during the latter part of the state fiscal year. “The family I visit with has many challenges in their life. Both parent being heavily delayed and having a four year old child with the movement of a three month old. I asked the mom what was her favorite part of the day with her child. She described in such detail how she loved to hold him and how he would wrap his left arm around her neck and use his index finger to slowly trace the side of her neck. How he enjoys falling asleep in her arms. Listening to this mom with so many battles that she faces daily speak with her heart about her child gave me so much life. It made me remember that when we meet families where they are instead of using our own values we're able to see how amazing they really can be.” – Pima County Healthy Families Arizona Annual Evaluation Report 2015 34 Exhibit 17. Percent of Families Showing No Child Abuse and Neglect Incidences Of all families with at least 6 months in the program in 2015, approximately 96% had no substantiated child abuse or neglect incidences. This is similar to the 2014 rate.                                                                                                     Collaboration with the Department of Child Safety Healthy Families Arizona provides supportive services for families involved with the Department of Child Safety (DCS). In state fiscal year 2015, 618 (17.9%) Healthy Families Arizona families had some level of involvement with DCS. This included the 144 families with substantiated cases, and 226 referred to Healthy Families Arizona from DCS workers. Healthy Families Arizona supportive services include: • acceptance of referrals from DCS; • providing screening and assessment for parent(s) if the parent(s) wished to determine eligibility to receive program services; attending DCS staffing; utilizing best practices and a family-centered approach when working with families; and coordinating with DCS staff to identify service needs and development of family and child goals. • • • Healthy Families Arizona Annual Evaluation Report 2015 35 It is hoped that the collaboration between Healthy Families Arizona and the Department of Child Safety will assist those families that may be at highest risk for child maltreatment. Child Development and Wellness While it is challenging to find ways to accurately measure child abuse and neglect, researchers do point to the benefits and impact that home visitors and home visiting can have on promoting optimal child growth and development in the families served. Home visitors are in a strategic position to help families obtain access to health resources and promote wellness. Immunizations and safety practices in the home are two indicators of child development and wellness reported this year. Immunizations The Healthy People 2020 goal is to have at least 90% of all children immunized with 4 doses of DTaP; 3 doses of IPV; one dose of MMR; 3 or more doses of Hib; 3 or more doses of Hep B vaccine; and 1 dose of Varicella vaccine by 2 years of age. This is referred to as the 4:3:1:3:3:1 immunization standard. For calendar year 2014, the Arizona immunization rate for 24 month olds was 66.1%, and the U.S. rate was 71.6% (www.cdc.gov). The Healthy Families Arizona program supports children obtaining all their necessary immunizations as a key step in preventing debilitating diseases. The home visitors encourage the families to follow through on completing their child’s immunizations and ask to check the family’s immunization booklet to record the dates of immunizations and assess completion. However, recently some families do not have booklets and say it is only recorded electronically. To help overcome this barrier, Healthy Families Arizona home visitors also track child wellness checks, and continuously follow up with families following these scheduled appointments to inquire about immunizations. This also allows home visitors to educate families regularly on the importance of their children receiving all recommended immunizations. Home visitors can also ask families to sign a release of information form (ROI) to obtain immunization information from their Pediatrician’s office, clinics, or other providers outside of their Pediatrician. In addition, Healthy Families Arizona has been given limited access to the Arizona Department of Health Services (ADHS) data to look up immunizations that children had received, and that families either did not have recorded in their vaccine books or were not given electronic printouts. These combined practices and systems assist families in ensuring they have the most up to date information on what immunization their children have or have not yet received. Exhibit 18 presents full immunization data at 12 months and 24 months, based on the recommended schedule of immunizations to meet Arizona state compliance of the 4:3:1:3:3:1 standard. Healthy Families Arizona families are modestly higher than the state immunization rate for 2-year olds and slightly lower than the national immunization rate Healthy Families Arizona Annual Evaluation Report 2015 36 for 2-year olds. The national immunization rate decreased substantially from 77.7% in 2013 to 74.6% in 2014. The immunization rates for 1-year olds in Healthy Families Arizona are the same as in 2014 while the rate for 2-year olds slightly decreased from last year. It may be beneficial for Healthy Families Arizona program staff to systematically continue investigating the factors that lead to families not being in compliance with the recommended immunization schedule, particularly for 2-year olds. Exhibit 18. Immunization Rate of Healthy Families Arizona Children 100% 80% 89.1% 71.0% 60% 67.2% 74.6% 40% 20% 0% HFAz 1 year HFAz 2 year Arizona 2 year U.S. 2 year *Source: 2014 data from the CDC National Immunization Survey. Safety Practices in the Home A study released by the Centers for Disease Control and Prevention (MMWR 2012) states that even though injury death for children have decreased from 15.5 to 11.0 per 100,000 population from 2000 to 2009, they continue to be the leading cause of death for children over the age of 1. Unintentional injuries are also the fifth leading cause of death for newborns and infants under the age of 1. A report in 2004, Home visiting and childhood injuries, concluded that home visits can reduce the risk of accidental injuries in the home by approximately 26 percent. The Healthy Families Arizona home visitors both assess and promote safe environments for children. The home visitors provide education about safety practices and monitor safety in the home through the completion of the safety checklist with the family. Exhibit 19 reports the use of four key safety practices across five time points for postnatal participants. Healthy Families Arizona Annual Evaluation Report 2015 37 Families that continue to participate in Healthy Families Arizona see increased safety practices and higher rates of safety. The National Highway Traffic Safety Administration in 2009 estimated the rate of child seat use for children under the age of 1 as 98%. The national rate for children between the ages of 1 to 3 however is estimated to be 96%. The families participating in Healthy Families Arizona maintain their high use of car seats over time (99% or more), indicating that the message of child safety in cars has been well received. The National Fire Protection Association reports that smoke detectors were present in only 72% of all reported home fires and operated in only 51% of home fires. Healthy Families Arizona households with working smoke alarms range from approximately 86% to 92%, improving the safety of the household environment for these families. Home visitors work with families on how to obtain a free smoke detector, and who to contact if their landlord is unable or unwilling to provide a working smoke detector in their home. Families also show relatively high rates of poisons locked, adding to the overall safety in the home. Although the percentage of participating families who have protective covers on electrical outlets steadily increases with time in the program, at all time points this percentage is below those for other safety practices. Home visitors utilize the safety checklist to discuss outlet covers with families as their baby begins to crawl. Families are encouraged to re-arrange their home furniture to cover exposed electrical outlets until they are able to access community resources for outlet covers. At six months the percentage goes from 38.7% to 51.3% which is when most babies begin to scoot and start to crawl. This percent increases to 71.1% when children turn 12 months which demonstrates that every time the safety checklist is completed with families they are understanding the importance of utilizing outlet covers as their children are growing and becoming more mobile. Exhibit 19. Percent of all Families Implementing Safety Practices Outlets Covered Poisons Locked Smoke Alarms Car Seats 2-Month 6-Month 12-Month 18-Month 24-Month 38.7% 51.3% 71.1% 77.4% 77.5% 85.5% 92.7% 95.8% 97.9% 98.3% 86.4% 99.7% 89.7% 99.9% 91.6% 99.8% 91.6% 99.9% 91.9% 99.8% “We do more things as a family now and have learned about safety” – Pima County Healthy Families Arizona Annual Evaluation Report 2015 38 Mothers’ Health, Education, and Employment The Healthy Families Arizona program also attempts to influence maternal life course outcomes. The home visitors encourage families to seek new educational opportunities, complete their high school education, obtain greater economic self-sufficiency, and obtain better paying and better quality jobs. Information is also provided to mothers regarding the positive health impacts of delaying subsequent pregnancies to at least 24 months. Subsequent Pregnancies and Birth Spacing Multiple births for some families can lead to increased stress and parenting difficulties, especially if the birth is unwanted or unplanned. Mothers with greater birth spacing have fewer pregnancy complications and are less likely to give birth to low birth weight or premature babies (Kallan, 1997). The home visitors emphasize the benefits of delaying repeat pregnancies and promote longer birth spacing for the mothers in the program. Exhibit 20 shows that the percentage of Healthy Families Arizona mothers who reported subsequent pregnancies increased to 7.3% in 2015 from 6.0% in 2014. Exhibit 20. Percentage of Mothers who Reported Subsequent Pregnancies State Fiscal Years 2012 to 2015 Percent of mothers with subsequent pregnancies 2012 2013 2014 2015 7.9% 7.6% 6.0% 7.3% For mothers in the Healthy Families Arizona program who have a subsequent pregnancy, there is a small percentage of women waiting at least two years. The Healthy People 2020 goal is to reduce the proportion of pregnancies conceived within 18 months of a previous birth down to 29.8%. Exhibit 21 below shows the length of time to subsequent pregnancy for those mothers who do have subsequent births. The low percentage of mothers that wait at least 2 years between subsequent births may be a reflection of some of the risk factors and barriers mothers face. For example, many of the families Healthy Families Arizona serve have Medicaid funded health plans which may place limitations on what birth control options can be prescribed by providers. Families that live in more rural areas or who rely on public transportation may struggle to get to scheduled doctor’s appointments. However, the percentage of mothers whose subsequent birth occurred 1 to 2 years later increased from 31.1% in 2014 to 43.6% in 2015. It would be beneficial for program staff to continue follow-up with families regarding short birth spacing. Healthy Families Arizona Annual Evaluation Report 2015 39 Exhibit 21. Length of Time to Subsequent Pregnancy for Those Families with Subsequent Births for Fiscal Years 2012 to 2015 Length of Time to Subsequent Pregnancy 1 to 12 mos. 13 to 24 mos. Over 24 mos. 2012 Percent of Mothers 2013 Percent of Mothers 2014 Percent of Mothers 2015 Percent of Mothers 59.9% 37.4% 2.7% 59.4% 40.1% 0.5% 67.7% 31.1% 1.2% 55.5% 43.6% 0.9% School, Educational Enrollment, and Employment Continued educational obtainment and increased employment are also important to consider when examining the program’s potential impact on maternal life course outcomes. Increased education is associated with better overall well-being and greater family stability. Exhibit 22 shows that part-time enrollment in education moves without a noticeable trend between the 6-month time point and the 24-month time point while full-time enrollment gradually decreases between the 12-month and 24-month time points. In fiscal year 2015, 12-13% of the mothers are enrolled in school either full- or part-time, which is fairly similar to the 11-14%enrolled in school in fiscal year 2014. Although the US economic recovery has continued to strengthen, the economy in Arizona has been slower to recover, maintaining higher than average unemployment rates and slower wage growth compared to US rates (US Bureau of Labor Statistics). Parents may have additional challenges in accessing or affording childcare, affording school, or having the time available away from work (or seeking employment) to attend school. Exhibit 22. Percent of Mothers Enrolled in School – State Fiscal Year 2015 6 month 12 month 18 month 24 month Percent enrolled part-time (2014 prior report) Percent enrolled full-time (2014 prior report) Percent enrolled part-time (2015) Percent enrolled full-time (2015) 5.8% 5.4% 5.7% 4.6% 7.4% 8.5% 7.6% 6.6% 5.3% 4.1% 6.0% 5.1% 7.3% 8.7% 6.5% 6.6% Maternal employment shows an increasing rate over time. Almost 33% of Healthy Families Arizona mothers are successfully employed at 6 months and approximately 49% at 24 months. Moreover, the full-time employment rates for mothers at 12 month, 18 months, and 24 months all increased from 2014 to 2015. According to Bureau of Labor Statistics data for 2014, 57.1% of mothers with children less than 1 year of age and 62.1% of mothers with children less than 3 years of age participate in the labor force. While increasing employment and income is fundamental for family well- Healthy Families Arizona Annual Evaluation Report 2015 40 being, there are complex realities facing families as they begin to increase their earnings. The importance of home visitors working with families in obtaining quality child care based on their natural resources is critical given the limited child care options currently available for families with low incomes. Exhibit 23. Mother’s Employment Status 100% Full-time Part-time 80% 60% 40% 20% 0% 12.5% 20.7% 25.1% 27.6% 32.9% 10.1% 14.0% 15.8% 17.2% 16.1% Baseline 6 months 12 months 18 months 24 months Substance Abuse Screening The relationship between substance abuse and the potential for child maltreatment is strong and well known (Pan, et al., 1994; Windom, 1992; Wolfe, 1998). When parents or caretakers are abusing substances, children may not be adequately cared for or supervised. While successful substance abuse treatment often requires intensive inpatient or outpatient treatment and counseling, home visitors can still play a critical role in screening for substance abuse, educating families about the effects of substance abuse on their health and the health of their children, and in making referrals for treatment services. Healthy Families Arizona uses the CRAFFT as a method of screening for substance use and abuse. The CRAFFT is a short screening tool for adults and adolescents to assess high risk drug and alcohol use disorders developed by the Center for Adolescent Substance Abuse Research (CeASAR), at the Children’s Hospital of Boston. A positive screen occurs if there are two or more “yes” answers out of six questions and indicates that further assessment and or referrals are recommended. Exhibit 24 presents data on the percent of families screened with the CRAFFT substance abuse screening tool and the percent of those families who screened positive for drug use. Approximately 34% of families screened at intake assessed positive for a history of substance use, putting them at potential risk. The number of families with positive Healthy Families Arizona Annual Evaluation Report 2015 41 substance abuse screens drops at 6 months to 7.5% and continues to drop at 12 months (5.6%). Moreover, the 2015 rates at all three time points are lower than those for 2014. Exhibit 24. Percent Screened and Assessed Positive on the CRAFFT Percent Time at assessment Screened 2 months (lifetime) 95.3% 6 months 12 months 94.5% 92.8% Percent Assessed Positive 40.8% 7.5% 5.6% Note: The 2 month screen asks lifetime substance use; later screens cover the past 6 months. “We have learned about resources that are easy and beneficial to our family. The advice and therapy provided by (the program staff) has helped bring us closer together. We love you guys! – Pima County 2015 Participant Satisfaction Survey The Healthy Families Arizona participant satisfaction survey provides valuable information for program staff and an opportunity for participants to reflect on their experiences. If participants are satisfied with the program and the work of the home visitor, they are more likely to benefit from the program. The following data summarizes the responses of participants who took the Healthy Families Arizona participant satisfaction survey in Spring 2015. The survey is distributed to all current participants in the program and returned by mail. A total of 3006 surveys were sent out and 2,062 surveys were returned, for a 68.6% return rate. The ethnic breakdown of these participants was similar to past years and is representative of the populations served by Healthy Families Arizona, with 56% Hispanic, 26% White, 8% American Indian, 4% African American, 4% Two or More Races, 1% Asian, less than 1% Hawaiian/Pacific Islander, and less than 1% Other. Exhibit 25 below shows key highlights from participant satisfaction survey responses. The exhibit presents the items which received the highest percent of strongly agree responses from participants and the items receiving the lowest percent of strongly agree. Based on the results of the survey it appears that participants feel they have good communication with their home visitors. Fewer Healthy Families Arizona participants (74.2%) agree strongly that finding services was easy compared to the responses for other questions, similar to responses in prior years. For the remaining statements in the satisfaction survey, more than 80% of the respondents strongly agreed. This is similar to the 2014 survey results and indicates a strong satisfaction level with the program. Healthy Families Arizona Annual Evaluation Report 2015 42 Exhibit 25. Percent Who Strongly Agreed on Satisfaction Survey Statements 2015 Finding Healthy Families services was Finding Healthy Families services was easy. easy. HealthyFamilies Familiesservices servicesare are scheduled scheduled at Healthy convenient times. convenient times. The fitsmy my TheHealthy HealthyFamilies Families program program fits family beliefs, cultures, values. family's beliefs, culture,and and values. Myfamily’s family'soverall overall experience experience with My withthe the Healthy Families program is good. Healthy Families program is good. The Healthy Families program provides The Healthy Families program provides the the support my family needs. support my family needs. I Ireceive frommy my receivehigh high quality quality services services from Healthy Families home visitor. Healthy Families home visitor. feltcomfortable comfortable discussing discussing my I Ifelt my concerns concerns with my Healthy with Healthy Families Familieshome homevisitor. visitor. TheHealthy HealthyFamilies Families program program staff The addresses my concerns. addresses my concerns. MyHealthy HealthyFamilies Families home home visitor does My does aa good jobjob explaining things to me. good explaining things to me. 74.2% 83.8% 81.8% 87.1% 83.9% 86.7% 87.1% 86.5% 88.7% I am satisfied with the information I I am satisfied with the information I receive. receive. 86.7% As a result of the Healthy Families As a result of the Healthy Families program, I program, I feel supported in growing as a feel supported parent. in growing as a parent. 86.5% recommend the Healthy Families I recommend Ithe Healthy Families program to program to others. others. My Healthy FamiliesFamilies home visitor refers me to My Healthy home visitor refers helpful community services. me to helpful community services. The Healthy Families materials and The Healthy Families materials and activities activities are respectful of my culture and are respectful of my culture and language. language. Healthy Families Arizona Annual Evaluation Report 2015 85.4% 85.0% 87.7% 43 Conclusions and Recommendations The 2015 state fiscal year has been productive for Healthy Families Arizona. The combined funding from the Department of Child Safety (DCS), First Things First (FTF), and the Department of Health Services (DHS) has increased the number of families receiving services throughout the state. The Healthy Families Arizona evaluation report focuses on the following primary outcome indicators: parent outcomes, child health and wellness, and child abuse and neglect. The results from the Healthy Families Parenting Inventory, participant tracking data sheets, safety checklists, screening tools, child abuse and neglect rates, and immunization rates all suggest that the Healthy Families Arizona program continues to address and reach most of its goals. The Healthy Families Arizona program uses evidence-based methods to guide the practice of home visitation. In order to continue to see successful outcomes and to improve other outcomes, the Healthy Families Arizona program needs to rigorously evaluate the program at least annually and use evidence for program improvement. Recommendations for this year are focused on ways the program can continue to emphasize quality programming, provide the most critical services to the highest risk families, and improve parent and child outcomes. • Encourage staff to continue strategies to increase retention. This year’s statewide one year retention rate is 68.6%. Research at the Cincinnati Children’s Hospital Medical Center in 2009 determined that some of the top reasons for dropping out of a home visitation program included: “home visitor did not help me get the things I needed”; “home visitor and friends/family gave conflicting advice”; and “hard to find time to meet because of work”. While, many families mentioned their satisfaction in learning about resources from their home visitor, it may be that some families need greater resource assistance sooner. Healthy Families Arizona puts a large emphasis on mobilizing resources starting from the very beginning of services. Time commitments are one of the most difficult areas for families, but Healthy Families Arizona home visitors are flexible in their home visitation schedules to provide the best options for families. • Review and update the program logic models to align with the Healthy Families America Best Practice Standards. The new Best Practice Standards from Healthy Families America went into effect in July 2014, and were updated in April 2015. Healthy Families Arizona has updated their Policies and Procedures Manual and the Healthy Families Arizona Annual Evaluation Report 2015 44 data collection forms to meet these new best practice standards. Healthy Families Arizona can use these to review and revise the program logic models to match the new critical elements outlined in the Best Practice Standards. Although many of the critical elements remain unchanged or similar, it would be useful to re-examine if the logic models are depicting the program as currently implemented. These logic models can be distributed and used by all program staff to maintain focus on key aspects of the intervention model. Training for program staff can support the use of the logic model to maintain sharp focus on fidelity to the model. • Reinforce the importance of developmental screening with home visitors and families. This year there was an increase in the percentage of children at 24 months old who screened as delayed. Reinforcing the importance of continued screening with home visitors and families, in addition to exploring barriers to completion of developmental screening, may increase the rate of screening even further, and potentially lead to additional or earlier referrals for developmental delays. Healthy Families Arizona Annual Evaluation Report 2015 45 References Ammerman, R.T. (2009) Increasing Retention in Home Visitation Final Report (R40MC06632). U.S. Department of Health and Human Services, Maternal and Child Health Research. Retrieved from: http://media.mchtraining.net/research/documents/finalreports/ammermanR40m c06632FinalReport.pdf Ammerman, R. T., Putnam, F. W., Bosse, N. R., Teeters, A. R., & Van Ginkel, J. B. (2010). Maternal depression in home visitation: A systematic review. Aggression and Violent Behavior, 15, 191–200. Anda, RF, Felitti, VJ, Bremner, JD, et al. (2006) The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. European Archive of Psychiatry Clinical Neuroscience. 256(3):174– 186. Barlow, A., Varipatis-Baker, E., Speakman, K., Ginsburg, G., Friberg, I., Goklish, N., Cowboy, B., Pields, P., Hastings, R., Pan, W. Reid, R., Santosham, M., & Walkup, J. (2006). Home-visiting intervention to improve child care among American Indian adolescent mothers. Arch Pediatric Medicine, 160, 1101-1107. Barlow, A., Mullany, B., Neault, N., Compton, S., et al. (2013) Effect of a Paraprofessional Home-Visiting Intervention on American Indian Teen Mothers’ and Infants’ Behavioral Risks: A Randomized Controlled Trial. The American Journal of Psychiatry. 170(1): 83-93. Boller, Kimberly, Deborah Daro, Patricia Del Grosso, Russell Cole, Diane Paulsell, Bonnie Hart, Brandon Coffee-Borden,Debra Strong, Heather Zaveri, and Margaret Hargreaves. “Making Replication Work: Building Infrastructure to Implement, Scale-up, and Sustain Evidence-Based Early Childhood Home Visiting Programs with Fidelity.” Children’s Bureau, Administration for Children and Families, U.S. Department of Health and Human Services. June 2014. Contract No.: GS-10F0050L/ HHSP233201200516G. Conron, K. J., Beardslee, W., Koenen, K. C., Buka, S. L., & Gortmaker, S. L. (2009). A longitudinal study of maternal depression and child maltreatment in a national sample of families investigated by child protective services. Archives of Pediatric and Adolescent Medicine, 63(10), 922–930. Healthy Families Arizona Annual Evaluation Report 2015 46 Duggan, A., Caldera, D., Rodriguez, K., Burrell, L., & Crowne, S. S. (2007). Impact of a statewide home visiting program to prevent child abuse. Child Abuse & Neglect, 31, 801-827. Duggan, A., McFarlane, E., Fuddy, L., Burrell, L., Higman, S. M., Windham, A. & Sia, C. (2004). Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse & Neglect, 28, 597–622. DuMont, K. Kirkland, K., Mitchell-Herzfeld, S., Ehrhard-Dietzel, S., Rodriguez, M. L., Lee, E., & Greene, R. (2011). A randomized trial of Healthy Families New York (HFNY): Does home visiting prevent child maltreatment? Retrieved from https://www.ncjrs.gov/pdffiles1/nij/grants/232945.pdf. Easterbrooks, M. A., Jacobs, F. H., Bartlett, J. D., Golderg, J., Contreras, M. M., Kotake, C., Raskin, M., & Chaudhuri, J. H. (no date). Initial findings from a randomized, controlled trial of Healthy Families Massachusetts: Early program impacts on young mothers’ parenting. Fang, X., D. S. Brown, C. S. Florence, and J. A. Mercy. (2012)The Economic Burden of Child Maltreatment in the United States and Implications for Prevention. Child Abuse and Neglect, 36: 156–65. Fergusson, D.M., Grant, H., Horwood, J., & Ridder, E.M. (2005). Randomized trial of the Early Start Program of Home Visitation. Pediatrics, 116(6), 803–809. Garner, A.S. (2001) Home visiting and the biology of toxic stress: opportunities to address early childhood adversity. Pediatrics, 132(S2): S65-S73. Haynes, G. W., Neuman, D., Hook, C., Haynes, D. C., Steeley, J.-M., Kelley, M., Gatterdam, A., Nielson, C. and Paine, M. (2015), Comparing Child and Family Outcomes Between Two Home Visitation Programs. Family and Consumer Sciences Research Journal, 43: 209–228. Howard, K. S., & Brooks-Gunn, J. (2009). The role of home-visiting programs in preventing child abuse and neglect. Future of Children, 19(2), 119–146. Kahn, J., & Moore, K. A. (2010). What works for home visiting programs: Lessons from experimental evaluations of programs and interventions. (No. #2010–17). Washington, DC: Child Trends. Lee, E., Mitchell-Herzfeld, S. D., Lowenfels, A. A., Greene, R., Dorabawila, V., & DuMont, K.A. (2009). Reducing low birth weight through home visitation: a randomized controlled trial. American Journal of Preventive Medicine, 36(2), 154-160. Healthy Families Arizona Annual Evaluation Report 2015 47 Michalopoulos, C., Lee, H., Duggan, A., Lundquist, E., Tso, A., Crowne, S., Burrell, L., Somers, J., Filene, J., & Knox, V. (2015). The Mother and Infant Home Visiting Program Evaluation: Early Findings on the Maternal, Infant, and Early Childhood Home Visiting Program. OPRE Report 2015-11. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Mitchell-Herzfeld, S., Izzo, C., Greene, R., Lee, E., & Lowenfels, A. (2005). Evaluation of Healthy Families New York (HFNY): First year program impacts. Renselaer, NY: New York State Office of Children & Family Services. Nievar, M. A., Van Egern, L.A., & Pollard, S. (2010). A meta-analysis of home visiting programs: Moderators of improvements in maternal behavior. Infant Mental Health Journal, 31(5), 499–520. Olds, D. L., Eckenrode, J., Henderson, C., Kitzman, H., Cole, R., Luckey, D.,…Baca, P. (2009). Preventing child abuse and neglect with home visiting by nurses. In K. A. Dodge, & D. L., Coleman (Eds.), Preventing child maltreatment: Community approaches. New York: Guilford. Peterson, C. A., Roggman, L. A., Green, B., Chazan-Cohen, R., Korfmacher, J., McKelvey, L. … Atwater, J. B. (2013). Home Visiting Processes: Relations with Family Characteristics and Outcomes. Zero to Three, 33(3), 39-44. Stevens, J., Ammerman, R.T., Putnam, F.G., & Van Ginkel, J.B. (2002). Depression and trauma history in first-time mothers receiving home visitation. Journal of Community Psychology, 30, 551–564. Stoltzfus, E., & Lynch, K. (2009). Home visitation for families with young children. Washington, DC: Congressional Research Service. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2015). Child Maltreatment 2013. Available from http://www.acf.hhs.gov/programs/cb/research-data-technology/statisticsresearch/child-maltreatment Healthy Families Arizona Annual Evaluation Report 2015 48 Appendix A. Team Level Data  Age of Child at Entry by Team .................................................................................. 49  Days  Top to Program Exit by Team .................................................................................. 50 Four Reasons for Program Exit by Team ......................................................... 51  Health Insurance at Intake by Team ......................................................................... 52  Late or No Prenatal Care or Poor Compliance at Intake by Team ....................... 53  Race of Mother by Team Prenatal ............................................................................. 54  Race of Mother by Team Postnatal ........................................................................... 55  Hispanic Ethnicity of Mother by Team .................................................................... 56  Gestational  Low Age by Team ........................................................................................... 57 Birth Weight by Team ........................................................................................ 58  Yearly Income by Team .............................................................................................. 59  Mother’s Parent Survey Score by Team ................................................................... 60  Trimester  Engaged of Enrollment into Prenatal Program by Team ..................................... 61 Prenatal Families that Exited before Baby’s Birth by Team .................. 62 Healthy Families Arizona Annual Evaluation Report 2015 49 Age of Child at Entry by Team– 2015 Mean Standard Number (Age in Days) Deviation Team 2 40.12 68 23.40 Team 3 41.79 73 26.46 Team 5 50.30 76 88.20 Team 6 15.00 84 14.04 Team 8 27.20 75 26.05 Team 9 22.40 90 18.64 Team 10 26.37 59 25.45 Team 11 22.53 45 19.47 Team 12 16.95 60 18.23 Team 13 16.88 43 22.22 Team 15 19.06 64 17.31 Team 17 16.12 65 14.06 Team 18 37.97 38 41.77 Team 19 46.06 97 36.18 Team 21 24.65 83 22.63 Team 23 47.70 90 26.22 Team 27 19.85 85 20.31 Team 28 20.31 54 19.26 Team 32 9.87 39 15.35 Team 33 28.20 35 15.53 Team 43 22.02 42 25.13 Team 48 43.28 86 89.27 Team 61 31.11 57 21.28 Team 62 35.20 70 25.00 Team 64 40.77 93 25.51 Team 65 46.46 85 76.82 Team 68 37.69 51 27.80 Team 70 19.87 79 23.04 Team 80 34.53 95 23.11 Team 81 19.37 76 16.89 Team 82 11.80 61 20.22 Team 83 37.90 100 24.24 Team 84 45.31 100 24.00 Team 85 12.84 49 18.05 Team 86 23.57 75 15.20 Team 87 20.87 31 16.48 Team 88 33.08 106 24.09 Team 89 39.33 84 26.06 Team 90 30.29 17 39.39 Team 91 12.90 21 20.81 Team 92 16.67 12 9.68 Total 30.47 2,713 35.58 Note: Total does not include data for families that enrolled in the prenatal period including those that did not receive prenatal services. Team Healthy Families Arizona Annual Evaluation Report 2015 50 Days to Program Exit by Team – 2015 (For families who left the program) Prenatal Median Mean St. Dev. Team 2 255.00 246.40 150.95 Team 3 356.50 356.50 136.47 Team 5 289.50 374.75 270.36 Team 6 424.00 562.25 321.92 Team 8 120.00 135.67 39.88 Team 9 746.00 686.71 219.64 Team 10 392.00 452.71 353.57 Team 11 206.00 408.00 330.96 Team 12 287.00 350.00 271.80 Team 13 231.00 245.44 141.40 Team 15 232.50 362.00 335.60 Team 17 303.00 319.21 212.57 Team 18 303.00 434.82 302.42 Team 19 276.00 270.15 159.27 Team 21 178.00 189.20 136.42 Team 23 326.00 344.67 138.72 Team 27 278.00 413.89 304.59 Team 28 346.00 349.75 196.48 Team 32 492.00 548.40 256.90 Team 33 352.50 433.03 229.45 Team 43 302.00 380.31 220.30 Team 48 813.00 652.00 328.55 Team 61 601.00 571.25 356.93 Team 62 251.00 248.15 114.10 Team 64 169.00 201.00 80.02 Team 65 294.00 405.17 279.30 Team 68 197.00 307.44 286.25 Team 70 233.00 233.00 57.98 Team 80 378.00 483.44 262.46 Team 81 384.50 473.90 278.01 Team 82 184.00 192.20 51.91 Team 83 209.00 293.67 198.78 Team 84 294.50 349.00 188.54 Team 85 267.50 389.88 257.15 Team 86 172.00 235.43 187.17 Team 87 330.00 326.40 22.28 Team 88 175.00 167.00 84.29 Team 89 278.00 304.71 138.71 Team 90 148.00 148.00 154.15 Team 91 109.50 109.50 65.76 Team 92 n/a n/a n/a Total 296.00 364.80 241.05 Note: St. Dev = Standard Deviation, # = Number of Families Team Healthy Families Arizona Annual Evaluation Report 2015 # 5 2 8 8 3 7 7 5 9 9 4 14 11 13 5 9 9 12 5 34 16 3 4 13 5 6 9 2 9 10 5 12 14 8 7 5 3 7 2 2 n/a 321 Median 242.00 249.50 397.00 318.00 242.00 324.00 584.00 329.50 323.00 285.00 326.50 267.00 330.00 224.00 345.00 260.00 279.00 428.00 235.50 200.00 211.50 311.50 507.00 331.00 235.50 209.00 255.50 463.00 174.00 274.00 337.00 205.00 187.00 252.00 277.00 317.00 205.00 221.00 253.00 91.50 n/a 277.00 Postnatal Mean St. Dev. 338.41 228.01 274.79 139.10 420.76 258.68 470.77 306.53 324.33 242.20 391.12 266.07 511.13 219.61 344.83 229.20 396.60 270.26 293.90 104.34 359.81 212.40 344.29 258.60 389.86 228.59 242.89 146.52 408.46 237.61 378.84 256.63 349.03 192.13 425.48 237.38 313.88 207.91 342.72 262.24 347.54 271.64 315.23 164.13 413.54 187.29 352.90 194.33 357.63 274.87 300.07 207.81 307.22 193.51 420.48 233.40 287.25 263.36 323.22 218.54 412.57 254.40 292.25 197.76 253.26 193.41 294.32 174.60 315.94 173.42 309.82 134.46 257.29 155.81 275.37 172.31 294.00 82.53 223.25 275.97 n/a n/a 339.15 225.56 51 # 22 28 25 26 24 43 16 18 25 10 16 21 7 35 35 31 31 27 8 18 28 22 13 41 24 41 18 23 40 36 37 32 53 22 35 11 41 30 3 4 n/a 1,021 Top Four Reasons for Program Exit by Team – 2015 Percent and Number within Team Overall (Prenatal and Postnatal Combined) Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total #1 Moved Away #2 Did Not Respond to Outreach Efforts % 25.9 10.0 9.1 32.4 14.8 8.0 8.7 17.4 23.5 52.6 60.0 42.9 44.4 20.8 25.0 27.5 7.5 35.9 38.5 26.9 15.9 16.0 11.8 7.4 21.4 10.6 23.1 40.0 10.2 23.9 9.5 16.3 7.5 10.0 19.0 6.3 11.4 8.1 20.0 66.7 100 19.4 % 18.5 26.7 27.3 0.0 33.3 34.0 8.7 13.0 11.8 5.3 10.0 2.9 16.7 14.6 12.5 15.0 60.0 20.5 7.7 7.7 25.0 12.0 29.4 16.7 17.9 27.7 15.4 0.0 14.3 21.7 28.6 11.6 20.9 36.7 16.7 25.0 25.0 5.4 0.0 16.7 0.0 18.9 n 7 3 3 11 4 4 2 4 8 10 12 15 8 10 10 11 3 14 5 14 7 4 2 4 6 5 6 10 5 11 4 7 5 3 8 1 5 3 1 4 1 260 Healthy Families Arizona Annual Evaluation Report 2015 n 5 8 9 0 9 17 2 3 4 1 2 1 3 7 5 6 24 8 1 4 11 3 5 9 5 13 4 0 7 10 12 5 14 11 7 4 11 2 0 1 0 253 #3 Family Refused Further Services % 14.8 23.3 27.3 17.6 18.5 22.0 17.4 17.4 11.8 26.3 0.0 17.1 16.7 16.7 15.0 20.0 20.0 20.5 7.7 0.0 6.8 28.0 35.3 24.1 25.0 2.1 38.5 16.0 30.6 21.7 7.1 18.6 32.8 10.0 11.9 37.5 20.5 32.4 0.0 0.0 0.0 18.7 n 4 7 9 6 5 11 4 4 4 5 0 6 3 8 6 8 8 8 1 0 3 7 6 13 7 1 10 4 15 10 3 8 22 3 5 6 9 12 0 0 0 251 #4 Self Sufficiency % 25.9 10.0 6.1 2.9 11.1 4.0 34.8 8.7 2.9 5.3 15.0 17.1 5.6 27.1 5.0 12.5 0.0 2.6 23.1 42.3 6.8 28.0 5.9 11.1 25.0 31.9 15.4 8.0 10.2 8.7 0.0 27.9 11.9 6.7 16.7 18.8 31.8 24.3 20.0 16.7 0.0 14.7 n 7 3 2 1 3 2 8 2 1 1 3 6 1 13 2 5 0 1 3 22 3 7 1 6 7 15 4 2 5 4 0 12 8 2 7 3 14 9 1 1 0 197 48 Health Insurance at Intake by Team – 2015 Percent and number within Team * Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total None % n 0.0 0 9.1 1 0.0 0 3.6 1 0.0 0 5.9 1 6.3 1 0.0 0 0.0 0 0.0 0 6.3 1 6.7 2 9.7 3 3.6 1 15.4 2 3.6 1 5.9 1 3.2 1 5.3 1 0.0 0 11.1 3 0.0 0 11.1 1 5.0 1 10.0 3 0.0 0 9.1 2 7.1 1 3.8 1 0.0 0 5.9 1 6.5 2 0.0 0 12.5 2 0.0 0 0.0 0 7.7 1 0.0 0 0.0 0 0.0 0 0.0 0 4.4 35 PRENATAL AHCCCS % n 91.7 11 81.8 9 91.7 22 92.9 26 100 14 76.5 13 87.5 14 80.0 8 85.7 12 96.2 25 93.8 15 90.0 27 83.9 26 96.4 27 69.2 9 85.7 24 82.4 14 74.2 23 78.9 15 87.0 40 81.5 22 100 15 88.9 8 85.0 17 83.3 25 93.3 14 81.8 18 92.9 13 96.2 25 100 20 94.1 16 90.3 28 87.5 21 81.3 13 100 9 94.1 16 92.3 12 93.3 14 75.0 6 80.0 4 85.7 6 88.0 696 Private % n 8.3 1 9.1 1 4.2 1 0.0 0 0.0 0 17.6 3 6.3 1 20.0 2 14.3 2 3.8 1 0.0 0 3.3 1 6.5 2 0.0 0 15.4 2 10.7 3 11.8 2 22.6 7 5.3 1 13.0 6 7.4 2 0.0 0 0.0 0 10.0 2 6.7 2 6.7 1 9.1 2 0.0 0 0.0 0 0.0 0 0.0 0 3.2 1 12.5 3 6.3 1 0.0 0 5.9 1 0.0 0 0.0 0 0.0 0 20.0 1 14.3 1 6.7 53 None % n 8.6 5 7.5 5 2.7 2 1.2 1 2.8 2 3.4 3 5.9 3 0.0 0 1.7 1 2.4 1 3.2 2 6.3 4 0.0 0 3.3 3 3.8 3 9.3 8 2.4 2 3.7 2 2.6 1 0.0 0 7.1 3 18.1 15 5.5 3 10.3 7 7.0 6 10.8 9 12.0 6 3.8 3 6.3 6 1.3 1 5.2 3 4.0 4 13.1 13 8.5 4 8.1 6 6.5 2 10.4 11 9.5 8 0.0 0 10.0 2 0.0 0 6.1 160 POSTNATAL AHCCCS % n 79.3 46 79.1 53 93.2 68 95.2 79 77.5 55 82.8 72 80.4 41 77.3 34 81.4 48 92.9 39 79.4 50 79.4 50 77.8 28 76.9 70 83.3 65 76.7 66 82.1 69 64.8 35 87.2 34 82.4 28 90.5 38 63.9 53 89.1 49 80.9 55 87.2 75 78.3 65 80.0 40 81.0 64 86.3 82 84.2 64 87.9 51 89.9 89 81.8 81 76.6 36 75.7 56 93.5 29 80.2 85 79.8 67 94.1 16 80.0 16 90.9 10 81.9 2,151 Private % n 12.1 7 13.4 9 4.1 3 3.6 3 16.9 12 13.8 12 13.7 7 22.7 10 16.9 10 4.8 2 15.9 10 14.3 9 22.2 8 18.7 17 12.8 10 12.8 11 15.5 13 31.5 17 7.7 3 17.6 6 2.4 1 18.1 15 5.5 3 7.4 5 5.8 5 10.8 9 8.0 4 13.9 11 7.4 7 14.5 11 6.9 4 6.1 6 5.1 5 14.9 7 16.2 12 0.0 0 9.4 10 10.7 9 5.9 1 10.0 2 9.1 1 11.7 307 *”Other” insurance percentages are not listed in this table but can be estimated by subtracting the sum of the other insurance categories from 100. Healthy Families Arizona Annual Evaluation Report 2015 49 Late or No Prenatal Care or Poor Compliance at Intake - 2015 by Site Percent and number ( ) within Team Did the mother have late or no prenatal care or poor compliance with prenatal care? Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total Yes 50.0% (6) 9.1% (1) 33.3% (8) 25.0% (7) 21.4% (3) 29.4% (5) 50.0% (8) 20.0% (2) 20.0% (3) 27.6% (8) 31.3% (5) 19.4% (6) 25.8% (8) 35.7% (10) 41.7% (5) 25.0% (7) 29.4% (5) 13.3% (4) 31.6% (6) 12.8% (6) 53.6% (15) 33.3% (5) 11.1% (1) 55.0% (11) 30.0% (9) 46.7% (7) 36.4% (8) 28.6% (4) 11.5% (3) 30.0% (6) 29.4% (5) 22.6% (7) 25.0% (6) 31.3% (5) 0.0% (0) 5.9% (1) 15.4% (2) 33.3% (5) 25.0% (2) 0.0% (0) 14.3% (1) 27.1% (216) PRENATAL No Unknown 50.0% (6) 0.0% (0) 90.9% (10) 0.0% (0) 66.7% (16) 0.0% (0) 75.0% (21) 0.0% (0) 78.6% (11) 0.0% (0) 70.6% (12) 0.0% (0) 50.0% (8) 0.0% (0) 80.0% (8) 0.0% (0) 80.0% (12) 0.0% (0) 69.0% (20) 3.4% (1) 68.8% (11) 0.0% (0) 77.4% (24) 3.2% (1) 74.2% (23) 0.0% (0) 64.3% (18) 0.0% (0) 58.3% (7) 0.0% (0) 75.0% (21) 0.0% (0) 70.6% (12) 0.0% (0) 86.7% (26) 0.0% (0) 68.4% (13) 0.0% (0) 85.1% (40) 2.1% (1) 46.4% (13) 0.0% (0) 66.7% (10) 0.0% (0) 88.9%(8) 0.0% (0) 45.0% (9) 0.0% (0) 70.0% (21) 0.0% (0) 53.3% (8) 0.0% (0) 59.1% (13) 4.5% (1) 71.4% (10) 0.0% (0) 88.5% (23) 0.0% (0) 70.0% (14) 0.0% (0) 70.6% (12) 0.0% (0) 77.4% (24) 0.0% (0) 70.8% (17) 4.2% (1) 68.8% (11) 0.0% (0) 100% (9) 0.0% (0) 82.4% (14) 11.8% (2) 84.6% (11) 0.0% (0) 66.7% (10) 0.0% (0) 75.0% (6) 0.0% (0) 100% (5) 0.0% (0) 85.7% (6) 0.0% (0) 72.0% 0.9% (573) (7) Healthy Families Arizona Annual Evaluation Report 2015 Yes 39.0% (23) 44.8% (30) 42.5% (31) 43.4% (36) 29.2% (21) 23.0% (20) 25.0% (13) 27.3% (12) 36.7% (22) 21.4% (9) 38.1% (24) 13.8% (9) 13.5% (5) 40.0% (36) 45.0% (36) 46.5% (40) 23.8% (20) 20.8% (11) 28.2% (11) 37.1% (13) 46.3% (19) 33.7% (28) 48.2% (27) 62.9% (44) 32.6% (28) 42.4% (36) 34.7% (17) 30.4% (24) 40.0% (38) 32.9% (25) 31.0% (18) 39.4% (39) 39.4% (39) 39.6% (19) 29.7% (22) 35.5% (11) 41.5% (44) 37.3% (31) 0.0% (0) 20.0% (4) 40.0% (4) 35.6% (939) POSTNATAL No Unknown 61.0% (36) 0.0% (0) 55.2% (37) 0.0% (0) 57.5% (42) 0.0% (0) 53.0% (44) 3.6% (3) 70.8% (51) 0.0% (0) 77.0% (67) 0.0% (0) 75.0% (39) 0.0% (0) 72.7% (32) 0.0% (0) 61.7% (37) 1.7% (1) 76.2% (32) 2.4% (1) 61.9% (39) 0.0% (0) 81.5% (53) 4.6% (3) 86.5% (32) 0.0% (0) 58.9% (53) 1.1% (1) 45.0% (36) 10.0% (8) 53.5% (46) 0.0% (0) 76.2% (64) 0.0% (0) 77.4% (41) 1.9% (1) 69.2% (27) 2.6% (1) 62.9% (22) 0.0% (0) 53.7% (22) 0.0% (0) 66.3% (55) 0.0% (0) 51.8% (29) 0.0% (0) 37.1% (26) 0.0% (0) 67.4% (58) 0.0% (0) 57.6% (49) 0.0% (0) 65.3% (32) 0.0% (0) 69.6% (55) 0.0% (0) 60.0% (57) 0.0% (0) 65.8% (50) 1.3% (1) 69.0% (40) 0.0% (0) 60.6% (60) 0.0% (0) 60.6% (60) 0.0% (0) 60.4% (29) 0.0% (0) 68.9% (51) 1.4% (1) 51.6% (16) 12.9% (4) 58.5% (62) 0.0% (0) 62.7% (52) 0.0% (0) 100% (17) 0.0% (0) 80.0% (6) 0.0% (0) 60.0% (6) 0.0% (0) 63.4% 0.9% (1,672) (25) 50 Race of Mother by Site PRENATAL – 2015 Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total Percent and number within Team Caucasian % 100 81.8 87.5 100 85.7 81.3 68.8 60.0 86.7 3.4 56.3 77.4 41.9 60.7 69.2 70.4 82.4 90.3 15.8 84.4 75.0 100 77.8 85.0 86.7 60.0 77.3 61.5 84.6 85.0 75.0 77.4 60.9 81.3 87.5 100 76.9 66.7 12.5 80.0 100 73.2 n 12 9 21 28 12 13 11 6 13 1 9 24 13 17 9 19 14 28 3 38 21 15 7 17 26 9 17 8 22 17 12 24 14 13 7 17 10 10 1 4 7 578 African American % n 0.0 0 18.2 2 8.3 2 0.0 0 0.0 0 6.3 1 12.5 2 20.0 2 0.0 0 0.0 0 6.3 1 3.2 1 0.0 0 14.3 4 0.0 0 14.8 4 5.9 1 0.0 0 0.0 0 0.0 0 3.6 1 0.0 0 0.0 0 5.0 1 0.0 0 26.7 4 9.1 2 15.4 2 3.8 1 10.0 2 6.3 1 19.4 6 34.8 8 0.0 0 12.5 1 0.0 0 23.1 3 13.3 2 0.0 0 0.0 0 0.0 0 6.8 54 Healthy Families Arizona Annual Evaluation Report 2015 Asian American % n 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 20.0 2 0.0 0 0.0 0 0.0 0 3.2 1 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 3.6 1 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 3.8 1 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.6 5 Native American % N 0.0 0 0.0 0 0.0 0 0.0 0 7.1 1 6.3 1 6.3 1 0.0 0 0.0 0 93.1 27 0.0 0 9.7 3 51.6 16 7.1 2 0.0 0 3.7 1 11.8 2 6.5 2 78.9 15 2.2 1 0.0 0 0.0 0 11.1 1 0.0 0 3.3 1 6.7 1 4.5 1 0.0 0 3.8 1 5.0 1 6.3 1 0.0 0 0.0 0 6.3 1 0.0 0 0.0 0 0.0 0 13.3 2 50.0 4 20.0 1 0.0 0 11.0 87 Mixed/ Other % n 0.0 0 0.0 0 4.2 1 0.0 0 7.1 1 6.3 1 12.5 2 0.0 0 13.3 2 3.4 1 37.5 6 6.5 2 6.5 2 17.9 5 30.8 4 11.1 3 0.0 0 3.2 1 5.3 1 13.3 6 17.9 5 0.0 0 11.1 1 10.0 2 10.0 3 6.7 1 9.1 2 23.1 3 3.8 1 0.0 0 12.5 2 3.2 1 4.3 1 12.5 2 0.0 0 0.0 0 0.0 0 6.7 1 37.5 3 0.0 0 0.0 0 8.4 66 51 Race of Mother by Site POSTNATAL – 2015 Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total Percent and number within Team Caucasian % 88.1 88.1 91.7 97.6 83.6 69.0 82.7 86.0 65.5 0.0 28.6 84.6 45.9 78.9 79.0 88.2 79.3 96.2 10.3 75.8 74.4 82.9 76.4 88.6 90.4 79.5 88.0 46.2 81.9 75.7 74.1 88.9 77.6 58.3 83.1 89.3 79.2 89.3 17.6 65.0 90.9 76.6 n 52 59 66 81 61 58 43 37 38 0 18 55 17 71 64 75 65 51 4 25 29 68 42 62 75 66 44 36 77 56 43 88 76 28 54 25 84 75 3 13 10 1,994 Healthy Families Arizona Annual Evaluation Report 2015 African American % n 10.2 6 7.5 5 2.8 2 0.0 0 4.1 3 8.3 7 1.9 1 2.3 1 1.7 1 0.0 0 0.0 0 1.5 1 0.0 0 8.9 8 3.7 3 2.4 2 8.5 7 1.9 1 0.0 0 3.0 1 0.0 0 9.8 8 14.5 8 7.1 5 6.0 5 7.2 6 6.0 3 0.0 0 9.6 9 5.4 4 3.4 2 8.1 8 15.3 15 12.5 6 3.1 2 3.6 1 12.3 13 8.3 7 0.0 0 0.0 0 0.0 0 5.8 151 Asian American % n 0.0 0 0.0 0 0.0 0 0.0 0 4.1 3 2.4 2 3.8 2 7.0 3 1.7 1 0.0 0 0.0 0 0.0 0 2.7 1 2.2 2 0.0 0 1.2 1 1.2 1 1.9 1 2.6 1 0.0 0 2.6 1 3.7 3 0.0 0 0.0 0 1.2 1 3.6 3 0.0 0 0.0 0 0.0 0 6.8 5 1.7 1 0.0 0 0.0 0 0.0 0 3.1 2 0.0 0 0.9 1 0.0 0 0.0 0 5.0 1 0.0 0 1.4 36 Native American % n 1.7 1 0.0 0 4.2 3 1.2 1 1.4 1 4.8 4 1.9 1 2.3 1 1.7 1 95.3 41 1.6 1 6.2 4 32.4 12 3.3 3 3.7 3 4.7 4 4.9 4 0.0 0 76.9 30 6.1 2 2.6 1 0.0 0 0.0 0 2.9 2 1.2 1 2.4 2 2.0 1 0.0 0 2.1 2 5.4 4 5.2 3 2.0 2 5.1 5 8.3 4 1.5 1 7.1 2 2.8 3 2.4 2 58.8 10 25.0 5 9.1 1 6.5 168 Mixed/ Other % n 0.0 0 4.5 3 1.4 1 1.2 1 6.8 5 15.5 13 9.6 5 2.3 1 29.3 17 4.7 2 69.8 44 7.7 5 18.9 7 6.7 6 13.6 11 3.5 3 6.1 5 0.0 0 10.3 4 15.2 5 20.5 8 3.7 3 9.1 5 1.4 1 1.2 1 7.2 6 4.0 2 53.8 42 6.4 6 6.8 5 15.5 9 1.0 1 2.0 2 20.8 10 9.2 6 0.0 0 4.7 5 0.0 0 23.5 4 5.0 1 0.0 0 9.8 255 52 Hispanic Ethnicity of Mother by Team– 2015 Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total Percent Hispanic Prenatal 41.7 45.5 45.8 100 71.4 47.1 62.5 30.0 33.3 3.4 81.3 32.3 35.5 35.7 46.2 57.1 76.5 38.7 15.8 17.0 25.0 80.0 77.8 70.0 53.3 40.0 50.0 71.4 73.1 70.0 70.6 67.7 45.8 87.5 33.3 52.9 69.2 53.3 37.5 20.0 28.6 49.7 Healthy Families Arizona Annual Evaluation Report 2015 Percent Hispanic Postnatal 64.4 57.4 57.5 96.4 75.3 52.9 69.2 43.2 41.7 7.0 88.9 27.7 29.7 29.7 14.8 58.1 53.6 55.6 15.4 11.4 33.3 75.9 71.4 70.0 53.5 60.0 60.0 82.3 58.9 52.6 79.7 81.8 52.5 58.3 28.4 58.1 66.0 44.0 23.5 25.0 81.8 55.5 Percent Hispanic Total 60.6 55.7 54.6 97.3 74.7 51.9 67.6 40.7 40.0 5.6 87.3 29.2 32.4 31.1 19.1 57.9 57.4 49.4 15.5 14.6 30.0 76.5 72.3 70.0 53.4 57.0 56.9 80.6 62.0 56.3 77.6 78.5 51.2 65.6 28.9 56.3 66.4 45.5 28.0 24.0 61.1 54.1 53 Gestational Age by Team – 2015 (Number and Percent within Team) Was the gestational age less than 37 weeks? PRENATAL No Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total % 77.8 87.5 91.3 95.8 78.6 92.9 100 80.0 100 100 100 100 100 83.3 88.9 69.2 88.2 91.7 100 86.5 92.0 92.3 77.8 93.3 88.0 81.8 95.0 100 100 66.7 80.0 87.0 95.0 92.9 100 100 100 84.6 100 75.0 100 90.3 Yes n 7 7 21 23 11 13 9 8 8 7 11 23 31 20 8 18 15 22 17 32 23 12 7 14 22 9 19 10 19 12 4 20 19 13 7 14 8 11 6 3 6 569 Healthy Families Arizona Annual Evaluation Report 2015 % 22.2 12.5 8.7 4.2 21.4 7.1 0.0 20.0 0.0 0.0 0.0 0.0 0.0 16.7 11.1 30.8 11.8 8.3 0.0 13.5 8.0 7.7 22.2 6.7 12.0 18.2 5.0 0.0 0.0 33.3 20.0 13.0 5.0 7.1 0.0 0.0 0.0 15.4 0.0 25.0 0.0 9.7 n 2 1 2 1 3 1 0 2 0 0 0 0 0 4 1 8 2 2 0 5 2 1 2 1 3 2 1 0 0 6 1 3 1 1 0 0 0 2 0 1 0 61 % 67.6 77.8 73.3 92.9 76.0 92.2 78.0 88.6 85.0 90.7 92.2 89.1 89.2 74.2 84.0 74.4 88.2 94.4 91.7 85.3 90.2 81.4 87.7 75.4 73.1 84.5 78.0 89.7 84.2 90.8 86.9 88.9 81.8 81.3 86.7 100 85.7 83.3 94.1 100 83.3 84.0 POSTNATAL No Yes n % 46 32.4 56 22.2 55 26.7 78 7.1 57 24.0 83 7.8 46 22.0 39 11.4 51 15.0 39 9.3 59 7.8 57 10.9 33 10.8 72 25.8 68 16.0 67 25.6 75 11.8 51 5.6 33 8.3 29 14.7 37 9.8 70 18.6 50 12.3 52 24.6 68 26.9 71 15.5 39 22.0 70 10.3 80 15.8 69 9.2 53 13.1 88 11.1 81 18.2 39 18.8 65 13.3 25 0.0 90 14.3 70 16.7 16 5.9 20 0.0 10 16.7 2,257 16.0 54 n 22 16 20 6 18 7 13 5 9 4 5 7 4 25 13 23 10 3 3 5 4 16 7 17 25 13 11 8 15 7 8 11 18 9 10 0 15 14 1 0 2 429 Low Birth Weight by Team – 2015 (Number and Percent within Team) Did the child have low birth weight? (less than 2500 grams, 88 ounces, or 5.5 pounds) PRENATAL Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total No % 80.0 100 89.5 100 85.7 88.9 100 75.0 100 93.3 100 100 92.9 95.5 87.5 69.6 88.9 95.5 100 84.8 88.9 100 100 100 95.8 88.9 94.4 100 95.0 76.9 85.7 76.9 81.3 100 100 100 100 100 83.3 100 100 91.8 Yes n 8 8 17 16 12 8 11 6 5 14 11 20 26 21 7 16 8 21 17 28 24 12 7 13 23 8 17 12 19 10 6 10 13 10 6 10 7 11 5 4 6 513 Healthy Families Arizona Annual Evaluation Report 2015 % 20.0 0.0 10.5 0.0 14.3 11.1 0.0 25.0 0.0 6.7 0.0 0.0 7.1 4.5 12.5 30.4 11.1 4.5 0.0 15.2 11.1 0.0 0.0 0.0 4.2 11.1 5.6 0.0 5.0 23.1 14.3 23.1 18.8 0.0 0.0 0.0 0.0 0.0 16.7 0.0 0.0 8.2 n 2 0 2 0 2 1 0 2 0 1 0 0 2 1 1 7 1 1 0 5 3 0 0 0 1 1 1 0 1 3 1 3 3 0 0 0 0 0 1 0 0 46 % 72.1 79.2 79.5 96.2 78.1 94.2 79.3 88.9 91.4 92.9 92.7 93.8 85.7 72.5 88.8 76.5 87.8 92.5 92.3 97.1 90.2 82.3 92.6 84.1 76.1 90.5 81.6 91.8 88.2 91.5 88.1 90.2 84.4 80.9 91.7 93.5 87.5 87.7 93.8 90.5 100 86.5 POSTNATAL No Yes n % 49 27.9 57 20.8 58 20.5 76 3.8 57 21.9 81 5.8 46 20.7 40 11.1 53 8.6 39 7.1 51 7.3 61 6.2 30 14.3 66 27.5 71 11.3 65 23.5 72 12.2 49 7.5 36 7.7 33 2.9 37 9.8 65 17.7 50 7.4 58 15.9 67 23.9 76 9.5 40 18.4 67 8.2 82 11.8 65 8.5 52 11.9 83 9.8 76 15.6 38 19.1 66 8.3 29 6.5 91 12.5 71 12.3 15 6.3 19 9.5 10 0.0 2,247 13.5 55 n 19 15 15 3 16 5 12 5 5 3 4 4 5 25 9 20 10 4 3 1 4 14 4 11 21 8 9 6 11 6 7 9 14 9 6 2 13 10 1 2 0 350 Yearly Income by Team – 2015 Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total PRENATAL Median Number Yearly Income 13,200 7,632 9,600 9,660 6,126 14,000 13,200 11,300 10,500 9,600 3,080 13,200 9,600 9,660 0 12,600 10,800 10,800 4,800 15,900 10,450 21,600 14,400 10,800 9,900 7,680 3,216 10,782 11,718 9,600 7,200 9,840 12,540 17,898 8,640 14,400 12,000 14,400 1,800 12,000 30,000 10,800 Healthy Families Arizona Annual Evaluation Report 2015 12 11 24 28 14 17 16 10 15 29 16 31 31 28 13 28 17 31 19 46 28 15 9 20 30 15 22 14 26 20 17 31 24 16 9 17 13 15 8 5 7 797 POSTNATAL Median Number Yearly Income 12,000 10,800 12,000 7,500 13,032 10,740 11,610 11,200 12,000 10,000 13,200 17,280 12,000 8,472 0 12,000 11,928 20,696 7,142 12,000 12,000 14,400 12,000 12,000 10,500 12,468 10,728 12,480 10,968 10,800 8,520 14,400 12,000 9,060 16,200 14,400 10,860 12,060 8,376 14,700 12,000 12,000 59 68 73 83 73 87 52 44 60 43 63 65 37 91 81 86 84 54 39 35 42 83 56 70 86 85 50 79 95 76 59 99 99 48 74 31 106 84 17 20 11 2,647 56 Mother’s Parent Survey Score by Team – 2015 Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total 0 – 20 0.0% 0.0% 0.0% 17.9% 0.0% 0.0% 6.3% 0.0% 0.0% 0.0% 6.3% 3.2% 6.5% 0.0% 0.0% 7.1% 0.0% 3.2% 0.0% 2.1% 7.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 14.3% 0.0% 0.0% 5.9% 0.0% 0.0% 6.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.5% PRENATAL 25 – 40 45 – 65 16.7% 83.3% 36.4% 45.5% 41.7% 45.8% 78.6% 3.6% 35.7% 57.1% 47.1% 47.1% 31.3% 43.8% 50.0% 40.0% 20.0% 73.3% 55.2% 44.8% 50.0% 43.8% 58.1% 35.5% 45.2% 48.4% 32.1% 57.1% 53.8% 46.2% 25.0% 60.7% 41.2% 58.8% 45.2% 51.6% 26.3% 63.2% 19.1% 68.1% 25.0% 60.7% 53.3% 40.0% 44.4% 55.6% 50.0% 40.0% 24.1% 72.4% 40.0% 53.3% 18.2% 77.3% 50.0% 28.6% 19.2% 57.7% 25.0% 65.0% 29.4% 58.8% 35.5% 58.1% 37.5% 54.2% 56.3% 37.5% 66.7% 33.3% 70.6% 29.4% 7.7% 61.5% 20.0% 80.0% 25.0% 25.0% 60.0% 40.0% 57.1% 42.9% 38.4% 52.2% Healthy Families Arizona Annual Evaluation Report 2015 70+ 0.0% 18.2% 12.5% 0.0% 7.1% 5.9% 18.8% 10.0% 6.7% 0.0% 0.0% 3.2% 0.0% 10.7% 0.0% 7.1% 0.0% 0.0% 10.5% 10.6% 7.1% 6.7% 0.0% 10.0% 3.4% 6.7% 4.5% 7.1% 23.1% 10.0% 5.9% 6.5% 8.3% 0.0% 0.0% 0.0% 30.8% 0.0% 50.0% 0.0% 0.0% 6.9% 0 – 20 0.0% 2.9% 1.4% 8.4% 8.2% 3.4% 1.9% 2.3% 0.0% 0.0% 12.7% 0.0% 5.4% 0.0% 2.5% 1.2% 2.4% 5.6% 2.6% 0.0% 0.0% 0.0% 1.8% 1.4% 0.0% 1.2% 0.0% 10.1% 1.1% 5.3% 3.4% 3.0% 1.0% 6.3% 0.0% 6.5% 0.9% 0.0% 5.9% 5.0% 0.0% 2.6% POSTNATAL 25 – 40 45 – 65 22.0% 59.3% 26.5% 57.4% 19.4% 65.3% 83.1% 8.4% 56.2% 32.9% 46.0% 44.8% 73.1% 23.1% 61.4% 34.1% 43.3% 51.7% 65.1% 34.9% 65.1% 20.6% 67.7% 30.8% 54.1% 35.1% 16.5% 62.6% 45.7% 46.9% 20.9% 57.0% 54.8% 40.5% 66.7% 22.2% 50.0% 36.8% 48.6% 42.9% 42.9% 52.4% 32.5% 56.6% 26.8% 60.7% 24.3% 64.3% 24.4% 60.5% 27.1% 55.3% 34.0% 52.0% 60.8% 29.1% 30.5% 49.5% 44.7% 48.7% 44.1% 50.8% 31.3% 54.5% 26.3% 51.5% 43.8% 50.0% 74.3% 24.3% 67.7% 25.8% 33.0% 50.9% 16.7% 70.2% 47.1% 41.2% 65.0% 30.0% 81.8% 18.2% 42.2% 46.2% 57 70+ 18.6% 13.2% 13.9% 0.0% 2.7% 5.7% 1.9% 2.3% 5.0% 0.0% 1.6% 1.5% 5.4% 20.9% 4.9% 20.9% 2.4% 5.6% 10.5% 8.6% 4.8% 10.8% 10.7% 10.0% 15.1% 16.5% 14.0% 0.0% 18.9% 1.3% 1.7% 11.1% 21.2% 0.0% 1.4% 0.0% 15.1% 13.1% 5.9% 0.0% 0.0% 9.0% Trimester of Enrollment into Prenatal Program by Team - 2015 Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total 1st Trimester # 0 1 2 6 0 2 1 0 5 7 0 1 3 1 1 1 4 7 2 16 3 2 2 1 2 2 3 2 1 1 6 4 3 2 0 0 2 0 0 0 1 97 % 0.0 9.1 8.3 21.4 0.0 11.8 6.3 0.0 33.3 24.1 0.0 3.2 9.7 3.6 7.7 3.6 23.5 22.6 10.5 34.0 10.7 13.3 22.2 5.0 6.7 13.3 13.6 14.3 3.8 5.0 35.3 12.9 12.5 12.5 0.0 0.0 15.4 0.0 0.0 0.0 14.3 12.2 Healthy Families Arizona Annual Evaluation Report 2015 2nd Trimester # % 4 33.3 8 72.7 8 33.3 10 35.7 2 14.3 8 47.1 6 37.5 5 50.0 1 6.7 15 51.7 7 43.8 7 22.6 10 32.3 14 50.0 6 46.2 8 28.6 5 29.4 10 32.3 10 52.6 23 48.9 12 42.9 5 33.3 1 11.1 9 45.0 7 23.3 5 33.3 7 31.8 3 21.4 12 46.2 10 50.0 6 35.3 13 41.9 8 33.3 8 50.0 2 22.2 5 29.4 5 38.5 5 33.3 2 25.0 2 40.0 5 71.4 299 37.5 3rd Trimester # % 8 66.7 2 18.2 14 58.3 12 42.9 11 78.6 7 41.2 9 56.3 5 50.0 9 60.0 7 24.1 9 56.3 21 67.7 18 58.1 12 42.9 6 46.2 19 67.9 8 47.1 14 45.2 7 36.8 7 14.9 13 46.4 8 53.3 6 66.7 9 45.0 21 70.0 8 53.3 12 54.5 9 64.3 13 50.0 9 45.0 5 29.4 13 41.9 12 50.0 6 37.5 7 77.8 12 70.6 6 46.2 10 66.7 6 75.0 2 40.0 1 14.3 393 49.2 Other / Unknown # % 0 0.0 0 0.0 0 0.0 0 0.0 1 7.1 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 2 6.5 0 0.0 1 3.6 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 2.1 0 0.0 0 0.0 0 0.0 1 5.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 3.2 1 4.2 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 20.0 0 0.0 9 1.1 Total # 12 11 24 28 14 17 16 10 15 29 16 31 31 28 13 28 17 31 19 47 28 15 9 20 30 15 22 14 26 20 17 31 24 16 9 17 13 15 8 5 7 798 58 Engaged Prenatal Families that Exited Before Baby’s Birth By Team – 2015 Team Team 2 Team 3 Team 5 Team 6 Team 8 Team 9 Team 10 Team 11 Team 12 Team 13 Team 15 Team 17 Team 18 Team 19 Team 21 Team 23 Team 27 Team 28 Team 32 Team 33 Team 43 Team 48 Team 61 Team 62 Team 64 Team 65 Team 68 Team 70 Team 80 Team 81 Team 82 Team 83 Team 84 Team 85 Team 86 Team 87 Team 88 Team 89 Team 90 Team 91 Team 92 Total Total Families 12 11 24 28 14 17 16 10 15 29 16 31 31 28 13 28 17 31 19 47 28 15 9 20 30 15 22 14 26 20 17 31 24 16 9 17 13 15 8 5 7 798 Healthy Families Arizona Annual Evaluation Report 2015 # Closed Before birth 0 0 0 0 0 0 1 0 2 2 0 1 0 1 2 1 0 1 0 1 0 0 0 2 0 0 0 1 0 0 1 1 0 0 1 0 1 0 0 0 0 19 % Closed Before birth 0.0 0.0 0.0 0.0 0.0 0.0 6.3 0.0 13.3 6.9 0.0 3.2 0.0 3.6 15.4 3.6 0.0 3.2 0.0 2.1 0.0 0.0 0.0 10.0 0.0 0.0 0.0 7.1 0.0 0.0 5.9 3.2 0.0 0.0 11.1 0.0 7.7 0.0 0.0 0.0 0.0 2.4 59 Appendix B. Healthy Families Arizona Steering Committee Members Jenna Shroyer Esthela Navarro Department of Child Safety, Healthy Families Arizona Central Administration Ryan Carkhuff Community Member Becky Ruffner Prevent Child Abuse Arizona Committee Chairperson Mary Warren Prevent Child Abuse Arizona Michel Lahti Darlene Lopez LeCroy & Milligan Associates Samantha Martin Wellington Consulting Kelley Murphy Children’s Action Alliance Judy Krysik Arizona State University Ginger Ward Suzanne Schunk Southwest Human Development Joanne M. Karolzak Casa de los Niños Eric Schindler Pauline Haas-Vaughn Child and Family Resources Margaret Daggett Greater Phoenix Child Abuse Prevention Council Julie Rosen Erika Mendoza Parenting Arizona Mike Oxtoby Coconino Health Department Peggy Peixoto Cradles to Crayons Healthy Families Arizona Annual Evaluation Report 2015 Jessica Stewart Department of Health Service, Bureau of Women’s and Children’s Health 60 Appendix C. Parent Survey Parent Survey* Problem Areas and Interpretation (Mother & Father) Areas (Scales) 1. Parent Childhood Experiences (e.g., Childhood history of physical abuse and deprivation) 2. Lifestyle, Behaviors and Mental Health (e.g., substance abuse, mental illness, or criminal history) Range 0, 5, or 10 Interpretation/ Administration The Parent Survey comprises a 10-item rating scale. A score of 0 represents normal, 5 represents a mild degree of the problem and a 10 represents severe for both the Mother 0, 5, or 10 and Father Parent Survey Checklist items. The Parent Survey is an assessment tool and 3. Parenting Experiences (e.g., Previous or current CPS involvement) 0, 5, or 10 4. Coping Skills and Support Systems (e.g., Selfesteem, available lifelines, possible depression) 0, 5, or 10 5. Stresses (e.g., Stresses, concerns, domestic violence) Families Arizona Program. A family is considered eligible to receive the Healthy 0, 5, or 10 Families Arizona program if either parent scores 25 or higher. 0, 5, or 10 7. Expectations of Infant’s Developmental Milestones and Behaviors 0, 5, or 10 8. Plans for Discipline (e.g., infant, toddler, and child) 0, 5, or 10 10. Bonding/Attachment Issues prior to enrollment through an interview by a Family Assessment Worker from the Healthy 6. Anger Management Skills (e.g., Potential for violence) 9. Perception of New Infant is administered to the mother and father 0, 5, or 10 0, 5, or 10 A score over 25 is considered medium risk for child abuse and neglect, and a score over 40 Total Score 0 - 100 is considered high-risk for child abuse. * Modified from the Family Stress Checklist Healthy Families Arizona Annual Evaluation Report 2015 61 Appendix D. Healthy Families Arizona Prenatal Logic Model Long Term Outcom es P rogram R esources ∈ Reduced child abuse and neglect ∉ Increased child wellness and development Family Support Specialists; Family Assessment Workers; Clinical consultants; Quality Assurance/Training/Evaluation; Funding; Community based services, e.g., prenatal support & education programs, hospital programs, nutrition services, translation & transportation services, mental health, domestic violence, substance abuse services ∠ Strengthened family relations ∇ Enhanced family unity  Reduced abuse of drugs and alcohol Increase the family’s support network Assess family’s support systems Model relationship skills Foster connections to positive support sources Improve mother’s mental health Identify signs and history of depression, abuse, mental illness, substance abuse Review history of birthing Encourage medical assessment, referral and treatment if needed Encourage exercise, personal care, rest Educate on post partum depression H.F. Parenting InventoryPrenatal (HFPIP); FSS-23 HFPIP; FSS-23 Prenatal Program Objectives Increase parents’ health behaviors Increase the family members’ problem solving skills Improve nutrition Assess personal risk behaviors Identify major life stressors Educate and provide materials on nutrition during pregnancy, buying and choosing healthy foods, and requirements for healthy fetal development Educate on risk behaviors, lifestyle choices, community resources, affect of drugs, medicines on fetus Explore domestic violence, form safety plan Encourage help seeking and adoption of healthy behaviors HFPIP; FSS23; CRAFFT Increase empathy for the unborn baby Program Activities and Strategies Educate on problem-solving, goal setting. Use IFSP to review progress Educate on access to community resources, how to reach out Make referrals as needed for anger and stress management Teach stress reduction Provide referrals to WIC, other resources Encourage healthy celebrations Explore and assess issues around pregnancy, relationships, hopes, fears Discuss and educate about changes in body, sexuality during pregnancy Healthy Families Arizona Annual Evaluation Report 2015 HFPIP; FSS-23 Increase safety in the home environment Increase the delivery of healthy babies, free from birth complications Explore father’s feelings, childhood experiences, expectations, hopes and fears about baby and goals for fatherhood Assess, encourage and guide family in making needed safety arrangements, e.g. crib safety, car seat, pets, SIDS, child care, feeding Connect mother to prenatal care and encourage compliance with visits Educate about changes in intimacy, ways father can support mother Share developmental information about stages of development of fetus Encourage supportive relationships for father Encourage prebirth bonding and stimulation exercises (reading, touch, etc) Outcome Evaluation Measures HFPIP; FSS-23 Increase father involvement HFPIP; FSS-23 62 Educate on father’s legal rights and responsibilities HFPIP; FSS-23; father involvement scale Educate on baby temperaments, how to calm baby, Shaken Baby Syndrome, medical concerns Encourage STD testing Educate on symptoms requiring medical attention Promote breastfeeding and refer to resources Refer to parenting workshops Explore cultural beliefs about discipline HFPIP; FSS-23; Safety checklist HFPIP; FSS-23; FSS20P Appendix E. Healthy Families Arizona Postnatal Logic Model Long Term Outcom es Program Resources ∈ Reduced child abuse and neglect ∉ Increased child wellness and development ∠ Strengthened family relations ∇ Enhanced family unity  Reduced abuse of drugs and alcohol Increase the family’s support network Improve mother’s mental health Increase parents’ health behaviors Assess family’s support systems Identify signs and history of depression, abuse, mental illness, substance abuse Assess personal risk behaviors; Educate on dangers of specific risk behaviors Address issues of grief and loss Support family in making lifestyle changes and adopting healthy behaviors Model relationship skills Foster connections to positive support sources Educate on communication skills Encourage medical assessment, referral and treatment if needed Encourage/coa ch on exercise, personal care, rest Educate on post- partum depression Healthy Families Parenting Inventory (HFPI); FSS-23 HFPI; FSS-23 Educate on community resources Explore domestic violence, create safety plan Family Support Specialists; Family Assessment Workers; Clinical consultants; Quality Assurance/Training/Evaluation; Funding; Community based services, e.g., parenting support & education programs, nutrition services, translation & transportation services, mental health, domestic violence, substance abuse services Postnatal Program Objectives Increase the family members’ problem solving skills Improve family stability Increase parental competence Program Activities and Strategies Assess basic Provide empathy living skills and and support to needs; help family parent in parenting access housing, role Educate on education, job, problem-solving, and budget Teach child goal setting. Use management development, early IFSP to review services. brain development, progress temperament Coach parent to Educate on set and evaluate Address parental access to goals; teach basic expectations of community living skills child resources, how to reach out Promote use of Educate about community importance of Make referrals resources for self routines and rules as needed for sufficiency anger and stress Refer to parenting management Explore family groups and classes planning decisions Educate about effect of stress on child Identify major life stressors Increase positive parent-child interaction Promote and teach developmentally appropriate stimulation activities Educate about rhythm and reciprocity, reading baby’s cues Promote reading, bonding during feeding Encourage family activities, celebrations Coach on father involvement Improve child health and Optimize child development Complete developmental assessments and make referrals Address medical screenings, support well child checks, immunizations, and good nutrition habits Promote play, reading; provide links to early childhood programs Prevent child abuse and neglect Assess risk of child abuse and neglect Coach and guide in choices for child care Educate about consequences of child abuse and neglect Assess and Guide family in making safety arrangements, e.g., home and car safety Outcome Evaluation Measures HFPI; FSS-23; CRAFFT HFPI; FSS-23 Healthy Families Arizona Annual Evaluation Report 2015 HFPI; FSS-23 HFPI; FSS-23; father involvement scale HFPI; FSS-23 63 HFPI; FSS-23; Safety checklist; ASQ HFPI; FSS-23; FSS20