Minnesota Evidence-Based Fam-ily Home Visiting Grant ProgramREQUEST FOR PROPOSAL MATERIALSLetter of Intent Deadline: October 17, 2018

Proposal Deadline: December 14, 2018

Minnesota Evidence-Based Family Home Visiting Grant Program Request for Proposal Materials

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Community and Family Health DivisionMinnesota Department of HealthFamily Home Visiting SectionPO Box 64882St. Paul, MN 55164-0882651-201-4090www.health.state.mn.us/fhv/

September 26, 2018

Upon request, this material will be made available in an alternative format such as large print, Braille or audio recording. Printed on recycled paper.

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ContentsMinnesota Evidence-Based Family Home Visiting Grant Program.................................................0

Overview....................................................................................................................................3

Background............................................................................................................................3

General Information about the Request for Proposal............................................................3

Program Description..............................................................................................................5

Project Narrative........................................................................................................................9

Budget Section.........................................................................................................................15

Introduction.........................................................................................................................15

Incentives.............................................................................................................................15

Required Budget Forms.......................................................................................................16

Budget Scoring.....................................................................................................................16

Program Requirements............................................................................................................17

Submission Checklist............................................................................................................17

Forms....................................................................................................................................... 18

Form A: Application Face Sheet...........................................................................................19

Form B: Work Plan...............................................................................................................20

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Form C: Priority Population Assessment..............................................................................24

Form D: Budget Justification - Instructions..........................................................................26

Form E: Budget Justification and Summary.........................................................................32

Form F: Due Diligence Review..............................................................................................33

Form G: Indirect Cost Questionnaire...................................................................................37

Appendices.............................................................................................................................. 38

Appendix A: Criteria for Scoring Applications......................................................................39

Appendix B: Definitions........................................................................................................40

Appendix C: Home Visitor Staffing Plan...............................................................................44

Appendix D: Minnesota Family Home Visiting Evaluation Measures...................................45

Appendix E: Grant Agreement Sample.................................................................................47

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OverviewBackgroundIn 2017, the Minnesota state legislature awarded the Minnesota Department of Health $12 million in funding over state fiscal years 2018 and 2019 and $16.5 million per year starting in state fiscal year 2020 to start up or expand evidence-based home visiting programs.

Purpose of the FundingThe purpose of this Request for Proposals (RFP) is to identify organizations interested in starting-up or expanding selected evidence-based home visiting models to serve families in need. These models are to be implemented at the community level as part of a coordinated, integrated system of early childhood services.

The Minnesota EBHV Grant program has an estimated total amount of $26 million for grantee funding under this RFP for the period of May 1, 2019 – December 31, 2022. Continued funding may be available and is contingent upon grantee’s satisfactory performance and ongoing state funding. MDH anticipates funding up to 10 applicants under this RFP to provide evidence-based home visiting services to families in Minnesota.

Applicants may include community health boards, non-profits, and tribal nations. This funding is available to applicants ready to: 1) implement a new; or, 2) expand an existing evidence-based home visiting model. Grants support start-up and expansion needs including but not limited to training, staff, travel to client homes and reflective supervision.

Definitions, a list of defined terms used throughout this RFP, can be found in Appendix B.

General Information about the Request for Proposal This Request for Proposal (RFP) document provides the instructions, forms and information needed to complete the Evidence-Based Family Home Visiting (EBHV) grant application. It is suggested that these instructions and a copy of the Criteria for Grant Review Score Sheet (Appendix A), be examined prior to writing the application.

Minnesota Department of Health (MDH) staff will be available to provide limited consultation and guidance during the application process. All questions or requests for assistance must be submitted to Health.FHVGrants@state.mn.us. MDH Family Home Visiting staff should not be directly contacted with questions or requests for assistance related to the application. In addition, MDH will maintain Frequently Asked Questions on the MDH Family Home Visiting Grant s website , which will be updated as needed. Please note that MDH staff will not be able to help with writing the application.

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Application Review, Scoring, and Funding RecommendationsThis is a competitive grant application. Eligible applications will be reviewed and scored according to the Criteria for Scoring the Evidence-Based Home Visiting Grant applications (Appendix A).

Reviewers may include MDH staff, staff from state agencies with experience related to family home visiting, maternal and child health, and early childhood, or individuals who are familiar with or who have provided services to pregnant and parenting families. Reviewers will be required to identify any conflicts of interest and will not review an application if a conflict is identified.

Consideration will be given to distributing funds throughout the state and meeting the funding priorities identified in the Minnesota Statutes Minnesota Session Laws 2017, First Special Session, Chapter 6, Article 18, Section 3, Subdivision 2. Applications that reflect regional partnerships are encouraged. Final funding decisions will be made by MDH based on reviewer scores and comments, priority populations to be served, identified regional and community partnerships and general funding priorities of MDH, including the following:

Funding a range of programs and organizations including a diverse set of models to better serve the State’s diverse communities.

Assuring funding supports a balance between expansions of existing home visiting services and building capacity for new programs.

Assuring statewide geographic representation.

It is anticipated that grant award decisions will be made in March 2019. Applicants will be notified whether or not their grant application is selected for funding.

Awarded applicants that are not current vendors in the State’s SWIFT system will need to get set up as vendors before a grant agreement can be created. Instructions on how to do that will be sent out to awarded applicants after the awards are announced.

Grant agreements will be executed with the primary applicant agency and funds will be awarded to the primary applicant through the grant agreement. The effective date of the agreement will be May 1, 2019, or the date upon which all signatures to the agreement are obtained, whichever is later. The grant agreement will be in effect until December 31, 2022. There may be negotiations to finalize the work plan, grantee’s duties, and/or budget before a grant agreement can be fully executed.

The awarded applicant will be responsible for assuring the implementation of the work plan, compliance with all state and federal requirements, including worker’s compensation, nondiscrimination, data privacy, budget compliance, and reporting requirements.

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

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

Clearly mark all trade secret materials in its response at the time the response is submitted; Include a statement with its response justifying the trade secret designation for each item;

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

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

Program DescriptionThe goal of the Minnesota Evidence Based Home Visiting (EBHV) program is to equip pregnant women, parents and other caregivers with the knowledge, skills, and tools to achieve a healthy birth and assist their children in being physically, socially and emotionally healthy, safe, and ready to succeed in school. The overall goal of the Minnesota EBHV program is to:

Expand services provided through evidence-based home visiting models in Minnesota by coordinating with and building on federally and locally funded programs;

Improve coordination of services for pregnant women and families; and, Identify and provide comprehensive services to improve outcomes for pregnant women

and families.

The Minnesota EBHV program will support the implementation of evidence-based home visiting models in communities serving one or more of the following populations:

o Programs enrolling and serving families prenatally to three months post-par-tum

o Communities experiencing high povertyo Communities with high child maltreatment rateso Communities with high rates of infants born with low birth weight o Pregnant and parenting teenso Underserved racial/ethnic communitieso Tribal nations and tribal communitieso Incarcerated parentso Families experiencing homelessnesso Pregnant women and families experiencing substance abuseo Pregnant women and families with mental illness

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The initiative also contributes to the development of an integrated system of early childhood services to meet the complex and diverse needs of at-risk families and communities across Minnesota. Expected outcomes include improvements in maternal and prenatal health, infant health, and child health and development; reduced child maltreatment; improved parenting practices related to child development outcomes; improved school readiness; improved family socio-economic status; improved coordination of referrals to community resources and supports; and reduced incidence of injuries, crime, and intimate partner violence.

Funded applicants will be required to provide data and reports on participating families and services provided; participate in state evaluation efforts; coordinate services to ensure the complex and diverse needs of the identified at-risk communities are being met; and fulfill the grant requirements outlined in the grant agreement. Funding needed for collecting and submitting required evaluation data, including modifications to computer systems, should be included in the proposal submitted.

Eligibility CriteriaEligible applicants include community health boards, nonprofits, and tribal nations.

All applicants submitting an application for funding are advised that in accepting state dollars under this RFP, as a sub-recipient, they will be required to comply with all state laws, executive orders, regulations, and policies governing these funds.

All applicants must meet the following criteria in order to be considered eligible:

Serve or plan to serve families at-risk or with high needs.o Priority will be given to applicants who propose to serve one or more of the

following populations: Programs enrolling and serving families prenatally to three months post-

partum Communities experiencing high poverty Communities with high child maltreatment rates Communities with high rates of infants born with low birth weight Pregnant and parenting teens Underserved racial/ethnic communities Tribal nations and tribal communities Incarcerated parents Families experiencing homelessness Pregnant women and families experiencing substance abuse Pregnant women and families with mental illness

Start-up or expand one of the following evidence-based home visiting models: o Healthy Families America, o Nurse Family Partnership, o Family Spirit, o Early Head Start – Home Based, o Family Connects or o Parents as Teachers.

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Submit one application that includes all agencies who are applying as a multi-partner or regional collaboration. The application must describe the home visiting approach and program. Applicants may not submit more than one application requesting funding for the same population.

Select a defined community for which they will provide services. Applicants need to justify how the selected community is a viable and feasible area in which to provide services.

Applicants must provide documentation that demonstrates the capability and capacity for implementing (start-up or expansion), and sustaining a successful evidence-based home visiting model. In addition to the criteria listed above, grant applicants must meet the following criteria:

If starting a new evidence-based home visiting model, applicants must: apply to establish a new evidence-based home visiting model that is based on

community needs. meet an identified gap in the exisitng continuum of early childhood services and

complement, rather than duplicate, existing home visiting services.

be able to demonstrate an ability to reach their projected target caseload within one year of funding.

be able to demonstrate that they are supplementing, not replacing, existing funds being used for evidence-based home visiting services as of June 30, 2018.

If expanding an evidence-based home visiting model, applicants must:

demonstrate sufficient additional need in an identified area, and the ability to expand the current home visiting program to meet those needs.

have had an average enrollment of 85% or more of their target caseload for the period of July 1, 2018 – December 31, 2018.

be able to demonstrate an ability to reach their projected target caseload within one year of funding.

maintain their current level of funding for existing evidence-based home visiting programs.

be able to demonstrate that they are supplementing, not replacing, existing funds being used for evidence-based home visiting services as of June 30, 2018.

Questions and Information SessionsThere will be a technical assistance webinar to assist in writing the application. Applicants do not need to attend the webinar to submit an application. The technical assistance webinar will include a review of the main components of the grant application. Questions about the grant application will not be addressed during the webinar, but will be gathered, answered and posted on the Family Home Visiting web site.

The webinar will be held using WebEx technology so that applicants can participate at their desk using a computer with an internet connection and a phone line. The technical assistance

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webinar will be held on Thursday, October 11, 2018, from 2:00 – 3:00 pm. To participate in the webinar, click here.

All questions must be submitted to Health.FHVgrants@state.mn.us. MDH will post “Answers to Grant Application Questions” by October 26, 2018 on the Family Home Visiting web site and will be periodically updated.

Letter of IntentApplicants are strongly encouraged to submit a Letter of Intent (LOI) to apply for funding under this RFP. Letters should include:

The name of the primary applicant and any entities partnering with the primary applicant, if known, for this RFP;

Contact information for the primary applicant and any partnering entities, including phone number(s) and e-mail address(es);

Indicate whether applying for start-up or expansion; The proposed community or population and geographic area to be served; The anticipated evidence-based model(s) that will be funded under this request; and, The anticipated target caseload that would be served, if awarded, through this RFP once

the program is at full capacity.

A list of applicants that submit an LOI will be shared amongst all the applicants to allow for and encourage coordination where possible. Letters of Intent must be submitted electronically by 4:00 pm (CST) on October 17, 2018 to: Health.FHVGrants@state.mn.us with “EBHV LOI” included in the subject line.

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Project Narrative All grant applicants shall submit a comprehensive narrative description of community needs and resources and clearly justify why the selected evidence-based home visiting model is appropriate for addressing the identified gap in services for at-risk families. The capacity of the proposed program to enroll and maintain the projected target caseload must be clearly demonstrated. The applicant must describe its capacity and capability for meeting all programmatic data and reporting requirements. The applicant must also detail planned activities and a timeline necessary to achieve program goals and objectives.

For applicants providing new home visiting services, but not expanding existing services, the description should follow the points as written below. For those expanding existing home visiting services, the project narrative should be worded as it relates to the expanded service focus, justifying the need for such an expansion, and describing the capacity to provide additional services. For all applicants, the scope of the proposal described in narrative should reflect the EBHV grant program goals and priority populations.

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

A. Purpose, Goals and Objectives (one page or less)1. State the purpose of the project.2. Identify the goal(s) and objectives for the project. Typically, the goal(s) are stated

in a sentence, and the objectives are presented in a numbered list. 3. Objectives should support progress toward goals. This narrative should

summarize and reflect key objectives outlined in the Work Plan (Form B). Utilize the SMART objective framework: Specific, measurable, achievable, relevant, and time bound are characteristics of SMART objectives.

B. Selection of Proposed Evidence-Based Home Visiting Model (one page or less, not including attachments)For the purposes of this RFP, applicants must select to start-up or expand implementation of one of the following evidence-based home visiting models: Healthy Families America, Nurse-Family Partnership, Family Connects, Family Spirit, Early Head Start and Parents as Teachers.

1. Identify the evidence-based home visiting model selected for implementation and provide a letter of support or documentation from the model developer. Documentation includes the approved affiliate or implementation plan or an e-mail or letter from the model developer stating that the agency’s workplan and budget have been reviewed and deemed adequate to implement the proposed model with fidelity and that all proposed model adaptations have been reviewed and approved.

2. Provide documentation of agency support for initiation or expansion of program.

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3. Clearly describe how the specific needs of the community and at-risk families will be met by the selected evidence-based home visiting model and how that community was engaged in the selection of the model.

4. Clearly link the selected evidence-based home visiting model to documented gaps in the service area.

5. Describe how the program will identify and refer targeted families for enrollment in the proposed evidence-based home visiting program.

6. Describe any anticipated challenges and/or risks associated with the implementation of the selected evidence-based home visiting model and possible strategies for addressing these challenges.

7. Describe any anticipated challenges and/or risks to maintaining quality and fidelity to the model and possible strategies for addressing these challenges.

C. Organizational Capacity (one page or less)1. Describe any current and/or prior experience with implementing the selected

home visiting models and/or any other models, as well as the current capacity of your agency to support the model.

2. Demonstrate and document the infrastructure in place to budget and manage funds, submit invoices and reports on time, and provide or be able to hire and/or contract, for the provision of services. For previous or current home visiting grantees, describe your level of timeliness with invoicing and reporting submissions. Describe how you will address any current challenges with timely reporting and invoicing. Indicate how often your program and budget staff meet to discuss programs costs and billing.

3. Describe how the applicant organization’s staff, leadership and board reflect the priority population(s) (Form C) the applicant proposes to serve. If staff, leadership and board are not reflective of the population(s) served, describe the applicants’ efforts to be responsive to the proposed population.

D. Linkages and Collaboration (one page or less)1. Describe the existing continuum of home visiting services in the community. This

includes home visiting programs and services not included on this proposal. Please provide information on the following:

a. The number and types of home visiting programs and their respective providers in the community;

b. The models that are used by the identified home visiting programs;c. The eligibility requirements and number of clients currently being served;

and,d. Identified gaps and overlaps in the existing continuum of home visiting

services and how they will be addressed.e. Describe how you currently or plan to collaborate with other home

visiting programs to identify, counsel and refer families to the home visiting program that best fits their needs and has openings.

i. If you currently have a waitlist, describe successes and challenges with referring waitlisted families to other local home visiting programs.

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f. For counties co-located with a tribal nation or tribal community, describe how the county has reached out, or plans to reach out, to the tribe to inquire about any unmet need or potential partnerships to deliver home visiting services.

2. List your community and multi-disciplinary partners and describe how you currently or plan to collaborate with them to enhance the local early childhood system. Partners could include primary care providers, social workers, school districts, and child care providers. Provide specific examples.

E. Implementation Plan for the Proposed Evidence-Based Home Visiting Model (three pages or less).

1. Describe how you will recruit, hire, and retain trained and competent staff for all positions and provide high-quality supervision.

2. Describe the training requirements for the selected model, training needs, timeline and plan for obtaining training from the national model developer. Grantees should plan on securing the required trainings for each model without the assistance of MDH.

3. Describe specific activities for how you will implement the evidence-based home visiting model with fidelity and how fidelity will be maintained throughout the length of the grant.

4. Describe the plan for providing access to high quality reflective practice training and supervision for all home visitors and supervisors, including infant mental health consultation, and any challenges, and resolutions that may be encountered.

5. Describe how you will reach, engage, recruit, enroll, and retain the targeted families in need of home visiting services in the identified service provision areas. Specifically address community-wide outreach and screening processes in identifying and referring eligible families to the proposed program.

6. Describe specific activities that you will carry out to assure culturally and linguistically appropriate services. Include a description of how these activities support your identified priority population.

7. Provide a calculated estimate of the number of staff required to maintain the projected target caseload of families in the proposed program. Consider historical caseload and retention data for your program, if available. Complete the required Home Visitor Staffing Plan table using the template provided in Appendix C. Include a summary of staffing ratios of supervisors to home visitors to clients and how they meet the guidance specific to your chosen model.

8. A referral system involves regular communication with the partners who do or should provide referrals to your program, so that they understand the services, are encouraged to refer clients to your program, are familiar with the process for providing referrals, and can provide feedback on their experience with referrals to your program. Describe how you will expand, implement, and maintain a referral process to the home visiting program.

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Referral resources shall include, at a minimum, WIC, public health, family planning clinics, prenatal care (OB/GYNs, Family Practice, NPs, etc.), hospitals, clinics. Include other referral sources if identified (such as Child Protective Services, mental health services, child care, school nurses, social workers, etc.).

9. A referral system also involves communication with the programs that you refer your home visiting clients to. This aspect of the system also requires regular communication among partners and is more active than providing clients with a referral slip or a phone number to call. Describe your plan for providing referrals from your program to other community resources and how you will follow-up on referrals made.

10. Describe the community’s plans for sustainability of the home visiting program on an ongoing basis, and/or how the community will address the sustainability of the project during the project period.

11. Describe your history related to third party billing and reimbursement. Describe how you will meet the grant requirements to bill for eligible third party reimbursements (e.g. developmental screening, CHW or PHN eligible home visiting services under Medicaid).

12. Discuss your plans for establishing, or to continue utilizing, an existing, local advisory council to provide input on proposed home visiting services. List current and potential partners to serve on the advisory council, including representatives from the community to be served.

F. Cost per Family Cap (one page or less)

Applicants proposing to implement a long term evidence-based home visiting model are required to submit a grant budget that does not exceed $6,500/year as the cost per family. Cost per family is calculated by dividing the total third year annual budget by the applicant’s proposed number of third year annual target families. This cost cap is determined by average cost per family expenses both nationally and statewide across multiple evidence-based models and strives to ensure cost-effective use of grant funds. It is anticipated that costs in the first and second years may be slightly higher due to increased training costs and lower target caseloads. As an example, if an applicant is proposing to serve 100 families per year, the total amount requested under this grant should be no more than $650,000 per year (100 families x $6,500). This amount should be reflected in the grant budget.

Applicants proposing to implement Family Connects should follow the average costs per family outlined by the model developer.

MDH will consider applicants that submit a grant budget requesting a cost per family between $6,500 - $8,000*/year if the applicant demonstrates at least one of the following enhanced activities described below. These enhanced activities must go above and beyond the normal scope of implementing an evidence-based home visiting model. Efforts described must be incorporated into the corresponding objectives within the Work Plan (Form B) and clearly identified in the Budget Justification (Form E) as costs related to this exception.

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Enhanced activities include:

1. Targeted and Intensive OutreachDescribe how additional cost per family expenses will contribute to outreach above and beyond model requirements. List anticipated costs. Example: A plan to hire two community outreach workers in geographic areas and/or communities that have been identified by the applicant as needing additional and tailored outreach efforts.

2. Partnership CoordinationDescribe the necessity of additional costs to facilitate regional collaboration and partnerships. List anticipated costs. Example: for the development and ongoing support of intentional and innovative partnerships that require significant coordination across multiple partnering agencies delivering home visiting services.

*Applicants requesting a cost per family exceeding $8,000 will not be reviewed.

G. Data Collection and Reporting (two pages or less)Awarded applicants are responsible for submitting evaluation data as described in the current FHV Reporting Requirements document, which is posted on the MDH website and updated at least annually. Applicants should review this document for details of MDH FHV data collection systems and reporting methods.

Grantees may designate or subcontract with another organization that will report evaluation data to MDH on the grantee’s behalf. Grantees are responsible for ensuring that the designee or subcontractor submits evaluation data according to state requirements and timelines.

Applicants should allocate sufficient funds in their budget to support the collection and reporting of evaluation data, including staff time and computer systems. MDH will provide guidance and technical assistance to awarded applicants to establish and improve data collection and submission processes. The planned State FHV Evaluation Measures are listed in Appendix D.

Evaluation data reporting requirements for this grant may differ from data collection required by an evidence-based home visiting model developer, or from data collected by a grantee’s organization for case management purposes.

Provide a statement acknowledging that, if awarded, you are responsible for submitting evaluation data to MDH as described in the current FHV Reporting Requirements document.

Describe the methods and systems you will use to collect and report required evaluation data. Specifically include:

o Name of software or data system(s) that will be used to capture data on home visiting clients;

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o Planned data collection method (for example, paper forms completed by home visitors during/after visits, followed by data entry into electronic system; tablets or mobile devices used by home visitors and/or families);

o Roles of home visiting and administrative staff in data collection, data entry, and data submission to the state;

o Any local infrastructure, partnerships, or data linkages you plan to leverage (for example, shared data system with another program); and,

o Whether you will designate or subcontract with another entity to collect or report evaluation data. Identify the organization or subcontractor. Describe how you will ensure the outside entity will comply with state requirements for evaluation data.

Describe how you will monitor and improve evaluation data quality and integrity, including the accuracy, completeness, and timeliness of data collection and submission.

Describe your data safety and security policies and procedures, including protection of private data, limits to data access by staff, data system backups, and compliance with applicable state and federal laws such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99), and the Minnesota Government Data Practices Act.

Describe any anticipated barriers or challenges in the process of collecting and/or reporting evaluation data, and possible strategies for addressing these challenges. Include anticipated needs for resources or technical assistance to establish, update, or improve data collection and reporting processes.

H. Continuous Quality Improvement (one page or less)1. Describe your program’s experience with quality improvement.2. Describe your experience with quality improvement activities required by

the proposed evidence-based home visiting model.3. Describe how staff will be supported in conducting quality improvement

activities.4. Describe the data systems you will use for quality improvement

purposes, and how you will use those data systems to track progress, measure whether change ideas resulted in improvement, identify the need for course corrections, and how data will be used to drive decision-making.

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Budget SectionIntroductionBefore writing the budget, consider the specific activities planned and the resources (staffing, supplies, equipment, etc.) needed to conduct those activities. Are there resources already available? Are there resources that need to be purchased? Which items will need to be replaced during the grant period? Give consideration to the skills needed to carry out the grant activity and comply with any requirements, particularly the financial requirements of the grant. Salaries and Fringe should reflect the amount of staff needed to serve the proposed target caseload listed in the application. Travel, supplies, training and other costs should be in line with the amount of staff and number of families proposed to be funded under this grant. Budgeting for a financial staff person is allowable. Remember to include any training that will be needed for paid staff or volunteers.

Costs of entertainment, including amusement, diversion and social activities where no grant program information is disseminated, and any costs directly associated with such costs (tickets to shows/movies/sporting events, meals, lodging, rentals, transportation, and gratuities) are unallowable.

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

Incentives may include gift cards or specific items and may only be given to eligible participants. This includes:

Gift cards and infant supplies may be used as incentives for participating mothers and caregivers receiving evidence-based home visiting services.

Applicants must adhere to the following rules regarding incentives: A participant may not receive more than $50 worth of incentives per year. If using gift

cards as incentives, multiple cards can make up the $50 maximum as long as the $50 is not surpassed.

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

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

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

o address the use of incentives in the narrative of the RFP applicationo account for the incentives in the “Other” line of the budget justification

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o obtain MDH’s approval of the budget justification that includes the incentives

Required Budget FormsThe applicant will need to complete and submit the following budget forms. Detailed instructions are on each form. These budget forms are in addition to the programmatic forms required in this RFP listed on page 18.

Budget Justification and Summary (Form E) Budget Periods 1-4 (see page 25 for more information)

Due Diligence Form (Form F) Must be completed by non-profit applicants Indirect Cost Questionnaire (Form G) For non-CHB applicants only

Applicants are required to submit the Budget Justification and Summary (Form E) in the provided Excel format. Applicants may not submit the Budget Justification and Summary Form as a PDF. Form E is available with the RFP information on the Minnesota Department of Health, Family Home Visiting, Funding and Grants Management Section (http://www.health.state.mn.us/divs/cfh/program/fhv/grant.cfm)

Budget ScoringThe Budget Justification and Summary (Form E) will be used for reviewing and scoring the budget portion of the application. If supplementary information is included, it will not be taken into consideration for scoring purposes. Be sure to double check the calculations and use whole dollar amounts, no decimals.

Proposals seeking to expand an existing evidence-based home visiting model must clearly demonstrate that requested funding will not be used to supplant, or replace, current resources. State statute prohibits recipients of state funds from replacing current state, local, or agency funds with state funds. Existing funds for a project and its activities may not be displaced by state funds and reallocated for other organizational expenses.

No more than 10 percent of the grant amount, or up to your federally approved indirect rate, may be spent on costs associated with administering the grant (indirect).

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Program RequirementsSubmission Checklist

While not required, all potential applicants are strongly encouraged to submit a Letter of Intent to MDH by the due date listed below. A letter of intent does not bind an applicant to submit an application. Letters of Intent must be submitted electronically by 4:00 pm (CST) on Monday, October 17, 2018 to Health.FHVGrants@state.mn.us .

Current/previous grantees: go to SWIFT and login and confirm that your organization’s name, address, locations, banking information, phone numbers, and other contact information is correct.

All applicants should complete this short survey ( https://survey.vovici.com/se/56206EE32E879859 ) as part of the application process.

Project Narrative must be 12-point font, single spaced, with one inch margins, adhering to the page limits specified in parenthesis next to lettered section headings.

Letter of support, e-mail or documentation from the model developer that supports applicant’s ability to implement the chosen evidence-based model with fidelity.

Application Face Sheet (Form A) The Work Plan can be in 11-point font (Form B) Priority Population Assessment (Form C) Budget Justification and Summary (Form E, Excel format required) If applicant is a non-profit, the Due Diligence Review is required (Form F) and the

Additional Documentation Required Indirect Cost Questionnaire (Form G, for non-CHB applicants only. Home Visitor Staffing Plan (Appendix C) Cost per family does not exceed $8,000. If it exceeds $6,500, justification is required as

outlined in the Project Narrative, Section F All pages are numbered consecutively The entire application should be submitted via email to Health.FHVGrants@state.mn.us

The application must be limited to Word, Excel and/or PDF files. Submission deadline is 4:00 pm (CST) on Friday, December 14, 2018. No late or

incomplete applications will be accepted or reviewed. If applicant is using a fiscal agent, it must be stated on the Face Sheet. A fiscal agent is

an organization that assumes full legal and contractual responsibility for the fiscal management and award conditions of the grant funds and that has authority to sign the grant agreement. A fiscal agent is a different entity than the entity that will actually perform the work/grantee’s duties.

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FormsApplication Face Sheet (Form A)

Work Plan (Form B)

Priority Population Assessment (Form C)

Budget Justification Instructions (Form D)

Budget Justification and Summary (Form E)

Due Diligence (Form F)

Indirect Cost Questionnaire (Form G)

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Form A: Application Face SheetGeneral Applicant InformationApplicant Legal Name (do not use a “doing business as” name):      Business Address (street, city, state, zip):      Minnesota Tax Identification Number:      Federal Tax Identification Number:      SWIFT Vendor ID Numbers (if you have one):      

Director of Applicant Agency InformationName:      Business Address (street, city, state, zip):      Phone Numbers:      Email:      

Financial Contact for this ApplicationName:      Phone Numbers:      Email:      

Contact Person for this ApplicationName:      Business Address (street, city, state, zip):      Phone Numbers:      Email:      

Requested FundingTotal Amount Requested $     

AbstractProvide a three-to-five-sentence summary of your project that identifies the project’s purpose and goal(s). The summary should be clear, accurate, concise, and without reference to other parts of the application.     Name(s) of All Partnering Entities (See Appendix B for definition)     Community (ies) Served and Priority Population(s)     Type of grant: Start-up or Expansion     Evidence-Based Home Visiting Model(s)     

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

Signature of Authorized Agent for Applicant:       Date of Signature:      

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Form B: Work Plan Complete the information below:

CHB, Tribal Agency or Organization’s Name:

CHB, Tribal Agency or Organization’s Address:

Partner Agencies:

Work Plan Contact:

Work Plan Contact Email:

Work Plan Contact Phone:

General Information1. Target caseload number, per model and budget period:

Budget Period

NFP Family Spirit

Parents as Teachers

Early Head Start

Family Connects

HFA

#1

#2

#3

#4

Measurable activities

In the chart below list at least one objective and related activities within each of the ten topics identified. Be sure measurable activities are specific to the program’s identified target population, needs and implementation. “SMART” objectives are specific, measurable, achievable, relevant and time-bound. If your program is experiencing challenges, list activities that will address the challenges and move the program toward success. For CQI, identify your EBHV program’s current focus and list activities relevant to the focus on CQI.

TopicIn field below each topic, enter related applicant defined SMART objectives.

Activities Time Period Person responsible

1. Referral network; develop a referral network for incoming

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TopicIn field below each topic, enter related applicant defined SMART objectives.

Activities Time Period Person responsible

referrals to the program and resources that the program will refer families based on need.

Describe objectives here:Obj. 1.Obj. 2.etc.

Describe activities here, per objective

List start date to anticipated end date here, per objective

List key staff responsible for accomplishing each objective here

2. Continuous quality improvement; identify CQI team and develop CQI work plan.

Describe objectives here Describe activities here

List dates here List staff here

3. Community Advisory Board; identify members and purpose of the community advisory board.

Describe objectives here Describe activities here

List dates here List staff here

4. Program funding, budgeting and sustainability; develop a comprehensive summary of overall home visiting budget, including all major home visiting funding sources.

Describe objectives here Describe activities here

List dates here List staff here

5. Reflective practice; develop and implement a plan for how

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TopicIn field below each topic, enter related applicant defined SMART objectives.

Activities Time Period Person responsible

reflective practice will be provided for supervisors and home visitors throughout the grant.

Describe objectives here Describe activities here

List dates here List staff here

6. Required MDH reporting, including quarterly reports and monthly data submission.

Describe objectives here Describe activities here

List dates here List staff here

7. Model fidelity and accreditation; maintain model approval, affiliation or accreditation and retain model fidelity.

Describe objectives here Describe activities here

List dates here List staff here

8. Integrating into the early childhood system; develop a plan with community partners and implement throughout the grant.

Describe objectives here Describe activities here

List dates here List staff here

9. Meeting target caseload; achieve a full caseload of families to be served and maintain the caseload at 85%

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TopicIn field below each topic, enter related applicant defined SMART objectives.

Activities Time Period Person responsible

during the grant.

Describe objectives here Describe activities here

List dates here List staff here

10. Recruiting and enrolling families.

Describe objectives here Describe activities here

List dates here List staff here

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Form C: Priority Population AssessmentPriority will be given to applicants who propose to serve one or more of the following populations:

o Programs enrolling and serving families prenatally to three months post-par-tum

o Communities experiencing high povertyo Communities with high child maltreatment rateso Communities with high rates of infants born with low birth weight o Pregnant and parenting Teenso Underserved racial/ethnic communitieso Tribal nations and tribal communitieso Incarcerated parentso Families experiencing homelessnesso Pregnant women and families experiencing substance abuseo Pregnant women and families with mental illness

In order to demonstrate how the applicant will serve the specified at-risk or high need popula-tions within their region, the applicant must complete the following narrative section and table.

1. Identify the geographic area or community selected for implementation of the home vis-iting model. Provide a clear rationale for why the community(ies), regional collaboration or other geographic area has been selected and why it constitutes a reasonable area for service delivery.      

2. Identify and describe the families in greatest need of home visiting services in the selected geographic area or community, with consideration of the priority populations listed above.      

3. Using the data sources provided and linked below please provide the county/region spe-cific data for each priority population with data sources listed. In the far right column briefly respond to the following questions:

a) Within this population, quantify how many families the applicant anticipates serving and how that has been determined.

b) How does the applicant serve or plan to serve the population and how those strategies are appropriate for the population?

c) What is the applicant’s history of serving these populations?

4. Data Sources For each of the following indicators, please use the data provided and/or any

other sources necessary.o Teen births (by race and county): See “MN Teen Births and Birth Weight

Data FHV.pdf” available at the Minnesota Department of Health, Family

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Home Visiting, Funding and Grants Management Section (http://www.health.state.mn.us/divs/cfh/program/fhv/grant.cfm)

o Low birth weight (by race and county): See “MN Teen Births and Birth Weight Data FHV.pdf” available at the Minnesota Department of Health, Family Home Visiting, Funding and Grants Management Section (http://www.health.state.mn.us/divs/cfh/program/fhv/grant.cfm)

oChild maltreatment rates (by race and county, see tables starting on page 34): Minnesota Department of Human Services 2017 Child Maltreatment Report ( https://mn.gov/dhs/assets/2017-10-child-maltreatment- report_tcm1053-321461.pdf)

o Poverty level: Minnesota Department of Health Poverty and Income ( https://data.web.health.state.mn.us/poverty)

oRace and ethnicity: United State Census Bureau Fact Finder (https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml)

5. Per Population Assessment

Rates/Demographics County/Region Specific Data Response

[EXAMPLE: Teen Births]

[From 2013-2017, Teen Pregnancies in Chisago County accounted for 4% of all births.]

[Applicant will address this by conducting outreach, etc. to ensure this population has access to home visiting services. Applicant plans to do outreach to all pregnant teens with a goal of providing home visiting services to 85% of them. ]

Poverty            

Child Maltreatment            

Low Birth Weight            

Teen Births            

Race/Ethnicity            

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Form D: Budget Justification - Instructions

IntroductionYou will need to account for all of your grant program costs under six different line items. The following paragraphs provide detailed information on what costs are allowable and associated with each of the six lines. You will be required to show detailed calculations to support your costs. Failure to include the required detail could result in a delayed grant agreement if your application is selected for funding.

All costs under this grant must be prorated to reflect fair share of the expense to this program. For example, if a computer is purchased for one staff person who works .5 FTE on this grant and .5 FTE on another program, the cost for that computer should be split 50 – 50 by this grant and the other program.

It is strongly suggested that applicants incorporate into their budgets the costs of appropriate financial staff to provide financial oversight to the grant. This could be through contracting with an individual or organization or a direct hire.

Each partner providing evidence-based home visiting services is required to complete a Budget Justification form for each period listed below. The primary applicant/fiscal host should include the total budgets of partner agencies under “Other”:

Period 1: May 1, 2019 to June 30, 2020

Period 2: July 1, 2020 to June 30, 2021

Period 3: July 1, 2021 to June 30, 2022

Period 4: July 1, 2022 to December 31, 2022

Applicants are required to submit grant program costs listed below using the Excel format of the Budget Justification and Summary (Form E) that is provided. The file must be submitted as an Excel Workbook; a pdf will not be reviewed. Form E is available with the RFP information on the Minnesota Department of Health, Family Home Visiting, Funding and Grants Management Section (http://www.health.state.mn.us/divs/cfh/program/fhv/grant.cfm)

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

Any salaries from the administrative support, accounting, human resources, or IT support, MUST be supported by some type of time tracking in order to be included in the Salary and Fringe line. Salary and fringe expenses not supported by time reporting documentation may be included in the indirect line if these unsupported salaries and fringe were included on the Indirect Cost Questionnaire form and approved by MDH. Any salary and fringe expenses not

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supported, not included on the Indirect Cost Questionnaire, and not approved by MDH are unallowable and may not be charged to this grant.

A brief description of the key duties that each staff will perform MUST be included. Staffing ratios must conform to model guidance.

Full time equivalent (FTE): The percentage of time a person will work on this grant project. Each position that will work on this grant should reflect the following calculations:

EXAMPLE:Public Health Nurse: $30.40/hourly rate

x2,080/annual hours (or whatever your agency annual standard is)$63,232 annual salary

Multiply annual salary by your agency’s fringe rate:$63,232 annual salaryx 23% fringe rate (use your agency fringe rate, 23% is just an example)$14,543 fringe amount

Provide the breakdown of what your fringe rate includes: 6.20% FICA1.45% Medicare3.00% Retirement

12.35% Insurance 23.00% Total Fringe Rate

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

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

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

All staff must be prorated to the anticipated time that they will work on the grant. If a position needs to be hired, applicants must prorate the final salary to account for delays in posting, recruiting and hiring the position based on their typical agency hiring practices and history. For the above example in Budget Period 1, the position would be prorated for fourteen months as follows:

($38,888/12months) X 14 months = $45,369 charged to grant for this position

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

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

TravelBriefly explain and list the expected travel costs for staff working on the grant, including mileage, parking, hotel, and meals. Applicants must budget for home visitors and supervisors to attend:

Required essential trainings for their chosen home visiting model. (Could be out of state)

Annual two-day MN Home Visiting Conference (Metro location; Budget Periods 1-3) CQI Learning collaborative: two annual in-person meetings (Metro location; Budget

Periods 1-4; include one in-person meeting during the fourth budget period. Mileage for travel to home visits and reflective practice (or indicate if covered by

another funding source)

If project staff will travel during the course of their jobs or for attendance at educational events, describe the purpose of the event, how it supports the chosen home visiting model, and itemize the costs, frequency, and the nature of the travel. Grant funds cannot be used for out-of-state travel without prior written approval from MDH. Minnesota will be considered the home state for determining whether travel is out of state.

Examples of Mileage and Out of State Travel Justifications are below:

Mileage: 5,000 miles for home visits each year: 5,000 x .545 per mile (or current IRS rate) = $2,725

Out of State Travel for 5 day Family Spirit Training (2 HVs and 1 Supervisor) (Albuquerque, NM)

Airfare R/T $600 * 3 Staff = $1,800 Mileage 208 R/T *.545 = $113* 3 Staff = $340 Hotel $174 a night * 5 nights = $870 * 3 Staff = $2,610 Meals (calculate according to applicable policy):

o Tribal Nations would include: Per Diem (first and last days calculated at 75%) 1st- $44.25 * 2 + 59 *3 = $266 * 3 Staff = $798

o CHBs/Non-Profits would include Commissioner’s Plan rates: 5 full days of meals for 3 staff: $36 x 5 days x 3 staff=$540

Baggage Fees $50 R/T * 3 Staff = $150 Taxi/Shuttle Fees $68 R/T * 3 Staff = $204

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Non-tribal applicants:

Budget for travel costs (mileage, lodging, and meals) using the rates listed in the State of Minnesota’s Commissioner’s Plan (http://www.health.state.mn.us/divs/opi/gov/lphact/docs/travelexpenses.pdf ) .

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

Mileage will be reimbursed at the current IRS rate at the time of travel.

Tribal Nation applicants:

Budget for travel costs (mileage, lodging, and meals) using the rates provided by the General Services Administration (GSA) (http://www.gsa.gov/portal/category/100120) . Current lodging amounts and meal reimbursement rates vary depending on where the travel occurs in Minnesota.

Consult the breakdown of the GSA meal and incidental expenses reimbursements (http://www.gsa.gov/portal/content/101518) for current rates for Tribal Nations.

Mileage will be reimbursed at the current IRS rate at the time of travel.

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

The following are examples of supply and expense descriptions that should be provided:

25 Family Spirit workbooks for families x $125 per workbook = $3,125

FHV program & Growing Great Kids Curriculum supplies = 25 families x $20 per family= $500 (Scale covers, antiseptic cleaners, hand sanitizer, brochures, fact sheets, plug in covers, cupboard latches, safety alarms, safety gates, other FHV and safety supplies. Glue, markers, paints and brushes, Ziploc bags, shoelaces, ribbon, yarn, bells, stickers, pom-poms, fabric, felt squares, athletic socks, 3-ring binders, copy paper, laminating paper, and other GGK activity supplies, GGK books with disks).

Cell phones for 3.0 FTE home visitors: 3 X $50/phone x 12 months= $1,800

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

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The primary applicant should clearly label and include the budget period totals for each partner under this section.

Example of Other Costs and Justifications:

Partner Costs:Home Visiting Agency Partner 1: $225,000

Home Visiting Agency Partner 2: $179,000

Electronic Health Record License (PHDoc): 3 staff x $1,200/staff = $3,600

Family Spirit Registration Fee:

2 Home Visitors x $3,000 = $6,000 1 supervisor x $4,000 = $4,000

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

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

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

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

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

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

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

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

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

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

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

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

Third Party ReimbursementApplicants must list and provide a brief description of their anticipated amount of third party reimbursement, if they are able to bill for services.

Cost per FamilyFor applicants that submit a budget requesting a cost per family over $6,500, the costs must be described in detail in the Budget Justification (Form E). Applicants requesting a higher cost per family for implementing one or both of the activities below may not submit a budget requesting a cost per family over $8,000. Applicants requesting a cost per family exceeding $8,000 will not be reviewed.

The applicant must demonstrate at least one of the following enhanced activities described below that go above and beyond the normal scope of implementing an evidence-based home visiting model. Efforts described must be clearly identified in the Budget Justification (Form E) as costs related to this exception:

Targeted and Intensive Outreach Partnership Coordination

Please go to the Budget Justification and Summary (Form E) to complete the required budget information.

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Form E: Budget Justification and SummaryForm E is available with the RFP information on the Minnesota Department of Health, Family Home Visiting, Funding and Grants Management Section (http://www.health.state.mn.us/divs/cfh/program/fhv/grant.cfm) Titled “RFP Budget Template.xlxs”

Complete this form for each budget period listed on page 25 and each Partner Applicant as applicable. See Appendix B for definitions.

Use whole dollar amounts, no decimals.

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Form F: Due Diligence ReviewThe Minnesota Department of Health (MDH) conducts pre-award assessments of all grant recipients prior to award of funds in accordance with federal, state and agency policies. The Due Diligence Review is an important part of this assessment.

These reviews allow MDH to better understand the capacity of applicants and identify opportunities for technical assistance to those that receive grant funds.

Organization Information

Name of MDH Grant Program applying for:

Organization Name:

Organization Address:

If the organization has an Employer Identification Number (EIN), please

provide EIN here:

If the organization has done business under any other name(s) in the past

five years, please list here:

If the organization has received grant(s) from MDH within the past

five years, please list here:

Section 1: Organizational Structure Points

1. How many years has your organization been in existence?

☐ Less than 5 years (5 points)

☐ 5 or more years (0 points)

2. How many paid employees does your organization have (part-time and full-time)?

☐ 1 (5 points)

☐ 2-4 (2 points)

☐ 5 or more (0 points)

3. Does your organization have a paid bookkeeper?

☐ No (3 points)

☐ Yes, an internal staff member (0 points)

☐ Yes, a contracted third party (0 points)

SECTION 1 POINT TOTAL

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Section 1: Organizational Structure PointsSection 2: Systems and Oversight Points

4. Does your organization have internal controls in place that require approval before funds can be expended?

☐ No (6 points)

☐ Yes (0 points)

5. Does your organization have written policies and procedures for the following processes? Accounting Purchasing

Payroll

☐ No (3 points)

☐ Yes, for one or two of the processes listed, but not all (2 points)

☐ Yes, for all of the processes listed (0 points)

6. Is your organization’s accounting system new within the past twelve months?

☐ No (0 points)

☐ Yes (1 point)

7. Can your organization’s accounting system identify and track grant program-related income and expense separate from all other income and expense?

☐ No (3 points)

☐ Yes (0 points)

8. Does your organization track the time of employees who receive funding from multiple sources?

☐ No (1 point)

☐ Yes (0 points)

SECTION 2 POINT TOTAL

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Section 3: Financial Health Points

9. If required, has your organization had an audit conducted by an independent Certified Public Accountant (CPA) within the past twelve months?

☐ Not Applicable (N/A) (0 points) – if N/A, skip to question 10

☐ No (5 points) – if no, skip to question 10

☐ Yes (0 points) – if yes, answer question 9A

9A. Are there any unresolved findings or exceptions?

☐ No (0 points)

☐ Yes (1 point) – if yes, attach a copy of the management letter and a written explanation to include the finding(s) and why they are unresolved.

10. Have there been any instances of misuse or fraud in the past three years?

☐ No (0 points)

☐ Yes (5 points) – if yes, attach a written explanation of the issue(s), how they were resolved and what safeguards are now in place.

11. Are there any current or pending lawsuits against the organization?

☐ No (0 points) – If no, skip to question 12

☐ Yes (3 points) – If yes, answer question 11A

11A. Could there be an impact on the organization’s financial status or stability?

☐ No (0 points) – if no, attach a written explanation of the lawsuit(s), and why they would not impact the organization’s financial status or stability.

☐ Yes (3 points) – if yes, attach a written explanation of the lawsuit(s), and how they might impact the organization’s financial status or stability.

12. From how many different funding sources does total revenue come from?

☐ 1-2 (4 points)

☐ 3-5 (2 points)

☐ 6+ (0 points)

SECTION 3 POINT TOTAL

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Minnesota Office of Grants Management Policy 08-06 requires state agencies to assess a recent financial statement from nonprofit organizations before awarding a grant of over $25,000 (excluding formula grants).

Section 4: To be completed by nonprofit organizations with potential to receive award over $25,000 ONLY (excluding formula grants)

Points

13. Does your nonprofit have tax-exempt status from the IRS?

☐ No - If no, go to question 14

☐ Yes – If yes, answer question 13A

Unscored

13A. What is your nonprofit’s IRS designation?

☐501(c)3

☐ Other, please list:

Unscored

14. What was your nonprofit’s total revenue (income, including grant funds) in the most recent twelve-month accounting period?

Enter total revenue here: Unscored

15. What financial documentation will you be attaching to this form?

☐ If your answer to question 14 is less than $50,000, then attach your most recent Board-approved financial statement

☐ If your answer to question 14 is $50,000 - $750,000, then attach your most recent IRS form 990

☐ If your answer to question 14 is more than $750,000, then attach your most recent certified financial audit

Unscored

SignatureI certify that the information provided is true, complete and current to the best of my knowledge.

▪ SIGNATURE:      

▪ NAME & TITLE:      

▪ PHONE NUMBER:      

▪ EMAIL ADDRESS:      

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Form G: Indirect Cost Questionnaire

Nonprofits and Tribes are required to complete

BackgroundApplicants applying may request an indirect rate to cover costs that cannot be directly attributed to a specific grant program or budget line item. This allowance for indirect costs are a portion of any grant awarded, not in addition to the grant award. Please refer to Budget Justification Instructions, page 29, for more detailed information on indirect costs.

InstructionsPlease complete the information below and return this form as part of the application.

1. Name of applicant agency:      

2. Are you requesting an indirect rate? Yes No

3. Do you have an approved Indirect Cost Rate Agreement with a Federal agency? Yes and that is the rate being requested. Please submit a copy of your current rate with this completed form.

Yes but requesting a rate different from our Federally approved rate.       No – Please continue completing the rest of this form.

4. Non-federal indirect rate being requested:      Up to 10% of the direct expenses in the budget for the grant program listed above can be used for indirect costs per CFR Part 200 - Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards, and per MDH policy for State funds.

5. Please list the expenses included in your indirect cost pool below, or attach a copy of your current indirect cost allocation plan to this form.                                        

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AppendicesAppendix A Criteria for Scoring Applications

Appendix B Definitions

Appendix C Home Visitor Staffing Plan

Appendix D Minnesota Family Home Visiting Evaluation Measures

Appendix E Link to MDH Grant Agreement Sample

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Appendix A: Criteria for Scoring Applications

Each application will be evaluated and scored by members of a Review Panel established by MDH for this RFP. Reviewers will be selected based on their background, knowledge and experience in maternal and child health and early childhood development.

Each question must be answered within the section where it is asked. Information that pertains to a question in another section will not be counted towards the response. Reviewers will be instructed to only give credit for the response to each individual question within its designated section. Applicants are strongly encouraged to provide clear, succinct, and direct responses to each question in the space provided for that question.

Project Narrative and Work Plan (90%) Clear statement of purpose, goals and objectives Appropriateness of selected evidence-based home visiting model eligible for funding:

Healthy Families America, Nurse-Family Partnership, Family Connects, Family Spirit, Early Head Start or Parents as Teachers.

Organizational capacity Linkages and collaboration Implementation plan for the proposed evidence-based home visiting model Data collection and reporting Continuous quality improvement Work Plan Priority Population Assessment

Budget and Budget Justification (10%) Budget narrative description supports the activities described in the proposal Assurances that proposed funding will not supplant existing funds A reasonable budget to implement the expansion or program is proposed. The average

yearly cost per family once target caseload is reached will be taken into consideration. Adequate justification is provided for cost per family between $6,500 and $8,000. Applicants with a cost per family over $8,000 will not be reviewed.

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Appendix B: DefinitionsAt-Risk Family –Families experiencing risk-factors residing in identified communities and eligible to receive home visiting services.

Community – A community is a geographically distinct area that is defined by the applicant. Communities should be areas that hold local salience and may be defined as a neighborhood, town, city, county or other geographic area. Services provided within a particular community should be distinguishable from services provided in other communities.

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

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

Evaluation Data – Individual-level data collected on families served by the evidence-based home visiting model and reported to the State for evaluation purposes. All awarded applicants will be required to collect evaluation data on participating families, and enter or upload the data into a system designated by MDH. Evaluation data will include demographic and service data, as well as data needed to calculate process and outcome evaluation measures. A list of the planned state FHV evaluation measures is provided in Appendix D.

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

Expansion – For the purposes of this RFP, expansion includes using the evidence-based model currently being implemented by the local agency to serve 1) additional participants within the current service area; or 2) additional participants within an expanded service area (high need county(ies), zip codes).

High Need Area or Community – A community for which the following indicators demonstrate greater risk than Minnesota as a whole: premature birth, low-birth weight infants, and infant mortality, including infant death due to neglect, or other indicators of at-risk prenatal, maternal, newborn, or child health; poverty; crime; intimate partner violence; high rates of high school dropouts; substance abuse; unemployment; or child maltreatment.

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Home Visiting Models– Programs or initiatives in which home visiting is a primary service delivery strategy and in which services are offered on a voluntary basis to clients including, but not limited to, pregnant women, expectant fathers, and parents and caregivers of children ages birth to kindergarten entry, targeting specific participant outcomes. For the purposes of this RFP, the following evicence-based home visiting models are eligible for priority funding: Healthy Families America, Nurse-Family Partnership, Family Spirit, Family Connects, Early Head Start and Parents as Teachers. Information on these models and the model developers is available here.

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

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

Multi-partner – An partnerhsip that includes two or more counties, tribal nations, or non-profits.

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

Non-Profit Organization – An entity granted tax-exempt status by the Internal Revenue Services and that does not seek or produce a profit.

Partner Applicant – Entity that enters into an agreement with a primary applicant for the purpose of this grant and will provide home visiting services and implement the grant program as outlined in the proposal through a new or existing relationship with the primary applicant.

Primary Applicant – Entity that, if awarded, serves as the named grantee and fiscal agent for the grant award.

Priority Population – o Programs enrolling and serving families prenatally to three months post-par-

tumo Communities experiencing high povertyo Communities with high child maltreatment rateso Communities with high rates of infants born with low birth weight o Tribal nations and tribal communitieso Pregnant and parenting Teenso Underserved racial/ethnic communitieso Incarcerated parentso Families experiencing homelessness

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o Pregnant women and families experiencing substance abuseo Pregnant women and families with mental illness

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

Review Panel– A group of reviewers with backgrounds, knowledge and experience in maternal and child health and early childhood development selected by MDH to evaluate and score applications submitted in response to this RFP.

Supplant – To replace or take the place of. State statute prohibits recipients of state funds from replacing current state, local, or agency funds with state funds. Existing funds for a project and its activities may not be displaced by state funds and reallocated for other organizational expenses.

Target Caseload – The target caseload is the total number of family slots that will be added as a result of this funding. Only active cases as defined by the evidence-based home visiting model may be counted toward the target caseload when reporting. Awarded applicants will identify a target caseload that will be achieved and maintained throughout the grant agreement.

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

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Appendix C: Home Visitor Staffing Plan

Home Visitor, Supervisor, Other Staff Position

Home Visiting Model

FTE amount funded from EBHV grant (proposed)

Number of Family Slots (caseload) added if EBHV grant is funded

Total number of family slots to be served by this HV position

Existing Staff (Y/N)

Staff planning to hire (Y/N)

Sally Example NFP 0.5 12 24 Y N

Mary Supervisor NFP 0.2 0 0 Y N

Vacant Home Visitor

NFP 0.5 12 24 N Y

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Appendix D: Minnesota Family Home Visiting Evaluation Measures

Measure Name Measure Description

Preterm BirthPercentage of infants born to mothers enrolled in home

visiting prenatally who are born before 37 weeks 0 days of gestation

Low Birth Weight Percentage of mothers enrolled in home visiting during pregnancy who deliver a low birth weight (LBW) child.

BreastfeedingPercent of infants (among mothers who enrolled in home visiting prenatally) who were breastfed any amount at 6

months of age

Initiation of Breastfeeding Percent of mothers enrolled in home visiting during pregnancy who initiate and continue breastfeeding for at least 3 months.

Depression ScreeningPercent of primary caregivers enrolled in home visiting who are screened for depression using a validated tool within 3 months of enrollment (for those not enrolled prenatally) or within 3 months of delivery (for those enrolled prenatally)

ImmunizationsPercent of children enrolled in home visiting who are up-to-

date on immunizations per CDC recommendations at 3 months, 6 months, and 12 months

Postpartum CarePercent of mothers enrolled in home visiting prenatally or

within 30 days after delivery who received a postpartum visit with a healthcare provider within 8 weeks (56 days) of delivery

Inter-Birth IntervalPercentage of mothers participating in home visiting before

the target child is 3 months old and who stay in home visiting until the child is 18 months old, who have an inter-birth

interval of at least 18 months.

Developmental ScreeningPercent of children enrolled in home visiting with a timely screen for developmental delays using a validated parent-

completed tool

Social-Emotional Screening Percent of children enrolled in home visiting who receive social-emotional screening at 12 months of age.

Intimate Partner Violence Screening

Percent of primary caregivers enrolled in home visiting who are screened for intimate partner violence (IPV) using a

validated tool

Primary Caregiver Education

Percent of primary caregivers who enrolled in home visiting without a high school degree or equivalent who subsequently

enrolled in, maintained continuous enrollment in, or completed high school or equivalent during their participation

in home visiting

Completed Depression ReferralsPercent of primary caregivers referred to services for a positive screen for depression who receive one or more

service contacts

Completed Developmental Referrals

Percent of children enrolled in home visiting with positive screens for developmental delays (measured using a validated

tool) who receive services in a timely manner. This measure needs to be reported on for all target children, including those

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Measure Name Measure Description

from subsequent pregnancies after enrollment in the home visiting program.

Completed Social Emotional Referrals

Percent of children enrolled in home visiting with positive screens for social-emotional well-being concerns (measured

using a validated tool) who receive services in a timely manner

Intimate Partner Violence ReferralsPercent of primary caregivers enrolled in home visiting with

positive screens for IPV (measured using a validated tool) who receive referral information to IPV resources

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Appendix E: Grant Agreement SampleMinnesota Department of Health (http://www.health.state.mn.us/divs/cfh/program/paa/content/document/pdf/app1sga.pdf). This is sample language only. If awarded a grant your actual language may vary.

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