OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 29
CH 1 PERFORMANCE MEASURE
Goal: Well Child Visit
Level: Grantee
Domain: Child Health
The percent of programs promoting and/ or facilitating well-child
visits.
GOAL
To ensure supportive programming for well-child visits.
MEASURE
The percent of MCHB funded projects promoting and/ or
facilitating well-child visits.
DEFINITION
Tier 1: Are you promoting and/ or facilitating well-child visits in
your program?
Yes
No
Tier 2: Through what activities are you promoting and/ or
facilitating well-child visits?
Technical Assistance
Training
Product Development
Research/ Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Tracking/ Surveillance
Screening/ Assessment
Referral/ care coordination
Direct Service
Quality improvement initiatives
Tier 3: How many are reached through those activities?
(Report in Table 1: Activity Data Collection Form
)
# receiving TA
# receiving training
# products developed
# peer-reviewed publications published
# receiving information and education through outreach
# receiving screening/ assessment
# referred/care coordinated
# received direct service
# participating in quality improvement initiatives
Tier 4: What are the related outcomes in the reporting year?
% of child program participants who received recommended
well child visits.
1
Numerator: Number of child program participants whose
parent/ caregiver reports that they received the last
recommended well child visit based on the AAP schedule
well child visit as of the last assessment within the
reporting period.
Denominator: Total number of child program
participants in the reporting period.
Definition: A participant is considered to have received
the last recommended a well child visit based on the AAP
schedule when they have been seen by a healthcare
provider for preventive care, generally to include age-
appropriate developmental screenings and milestones, and
immunizations, in the month recommended by AAP. The
AAP recommends children be seen by a healthcare
1
Consistent with Healthy Start Benchmark 11: The percent of Healthy Start child participants who receive well child visits.
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 30
CH 1 PERFORMANCE MEASURE
Goal: Well Child Visit
Level: Grantee
Domain: Child Health
The percent of programs promoting and/ or facilitating well-child
visits.
provider for preventive care at each of the following ages:
by 1 month, 2 months, 4 months, 6 months, 9 months, 1
year, 15 months, 18 months, 24 months/ 2 years, 30
months, 3 years, and then annually thereafter.
2
% of children enrolled in Medicaid/ CHIP with at least one
well care visit in the past year
Numerator: Medicaid/ CHIP-enrolled child program
participants who received a well-child visit in the
reporting year.
Denominator: Total number of Medicaid/ CHIP-enrolled
child program participants in the reporting year.
BENCHMARK DATA SOURCES
National Survey of Children’s Health K4Q20
GRANTEE DATA SOURCES
Title V National Performance Measure #10,
SIGNIFICANCE
Routine pediatrician visits are important to (1) prevent illness and
injury through immunizations and anticipatory guidance, (2) track
growth and development and refer for interventions as needed, (3)
address parent concerns (e.g., behavior, sleep, eating, milestones),
and (4) build trusting parent-provider relationships to support
optimal physical, mental, and social health of a child.
3
2
https://www.aap.org/en-us/Documents/periodicity_schedule.pdf
3
https://www.aappublications.org/news/aapnewsmag/2015/12/15/WellChild121515.full.pdf
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 31
CH 2 PERFORMANCE MEASURE
Goal: Quality of Well Child Visit
Level: Grantee
Domain: Child Health
The percent of programs promoting and/ or facilitating quality of
well-child visits.
GOAL
To ensure supportive programming for quality of well child visits.
MEASURE
The percent of MCHB funded projects promoting or facilitating
quality of well child visits.
DEFINITION
Tier 1: Are you addressing the quality of well child visits in your
program?
Yes
No
Tier 2: Through what activities are you addressing quality of well
child visits?
Technical Assistance
Training
Product Development
Research/ Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Quality improvement initiatives
Tier 3: How many are reached through those activities?
# receiving TA
# receiving training
# product disseminated
# reached while guideline setting
# peer-reviewed publications published
# receiving information and education through outreach
# participating in quality improvement initiatives
See data collection form.
Tier 4: What are the related outcomes in the reporting year?
% providers trained in conducting a quality well-child visit
Numerator: # of providers trained.
Denominator:# of providers targeted through the program.
BENCHMARK DATA SOURCES
N/A
GRANTEE DATA SOURCES
Grantee self-reported.
SIGNIFICANCE
Comprehensive well-child visits include (1) complete history
about birth; prior screenings; diet; sleep; dental care; and medical,
surgical, family, and social histories, (2) head-to-toe examination
and review of growth, (3) immunization review and delivery, (4)
screening for postpartum depression in mothers of infants up to
six months of age, (5) age-appropriate health and development
screenings (e.g., developmental, vision, hearing, autism), (6) age-
appropriate guidance to address parent questions/concerns and
encouragement of positive parenting practices (e.g., screen time,
nutrition, physical activity, sleep), and (7) developmentally
appropriate injury prevention guidance (e.g., car seat safety,
bicycle helmet, substance use).
4
.
4
https://www.aafp.org/afp/2018/0915/p347.html
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 32
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 33
Providers/ Health Care
Professionals
Community/ Local
Partners
State or National
Partners
Technical Assistance
Training
Product Development
Research/ Peer-reviewed
publications
Guideline Setting
Outreach/ Information
Dissemination/
Education
Quality improvement
initiatives
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 34
CH 3 PERFORMANCE MEASURE
Goal: Developmental Screening
Level: Grantee
Domain: Child Health
follow-up for children.
GOAL
MEASURE
DEFINITION
screening and follow-up in your program?
Yes
No
Tier 2: Through what processes/ mechanisms are you promoting
or facilitating developmental screening and follow-up?
Technical Assistance
Training
Product Development
Research/ Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Tracking/ Surveillance
Screening/ Assessment
Referral/ care coordination
Direct Service
Quality improvement initiatives
Tier 3: How many are reached through those activities?
(Report in Table 1: Activity Data Collection Form
)
# receiving TA
# receiving training
# products developed
# peer-reviewed publications published
# receiving information and education through outreach
# receiving screening/ assessment
# referred/care coordinated
# received direct service
# participating in quality improvement initiatives
Tier 4: What are the related outcomes in the reporting year?
% of children 9 through 35 months receiving a
developmental screening using a parental-completed tool?
Numerator: Children of program participants aged 9
through 35 months who have received a developmental
screening using a parent/ caretaker-completed tool.
Denominator: Children, aged 9 through 35 months, of
BENCHMARK DATA SOURCES
proportion of children who receive a developmental screening.
GRANTEE DATA SOURCES
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 35
CH 3 PERFORMANCE MEASURE
Goal: Developmental Screening
Level: Grantee
Domain: Child Health
follow-up for children.
SIGNIFICANCE
well-being of children and their families. It is an integral function
of the primary care medical home. The percent of children with
a developmental disorder has been increasing, yet overall
screening rates have remained low. The American Academy of
Pediatrics (AAP) recommends screening tests at the 9, 18, and 24
or 30 month visit. The developmental screening measure is
endorsed by the National Quality Forum and is part of the Core
Set of Children’s Health Care Quality Measures for Medicaid
and CHIP.
5
5
Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee;
Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with
developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006
Jul;118(1):405-20. Reaffirmed November 2014. http://pediatrics.aappublications.org/content/118/1/405
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 36
CH 4 PERFORMANCE MEASURE
Goal: Injury Prevention
Level: Grantee
Domain: Child Health
The percent of programs promoting and/ or facilitating injury
prevention among children.
GOAL
To ensure supportive programming for injury prevention among
children.
MEASURE
The percent of MCHB funded projects addressing injury
prevention and through what processes.
DEFINITION
Tier 1: Are you promoting and/ or facilitating injury prevention
among children in your program?
Yes
No
Tier 2: Through what processes/ mechanisms are you addressing
injury-prevention? See data collection form.
Technical Assistance
Training
Research/ dissemination
Peer-reviewed publications
Outreach/ Information Dissemination/ Education
Referral/ care coordination
Quality improvement initiatives
Use of fatality review data
Please check which child safety domains which program
activities were designed to impact:
Motor Vehicle Traffic
Suicide/ Self-Harm
Falls
Bullying
Child Maltreatment
Unintentional Poisoning
Prescription drug overdose
Traumatic Brain Injury
Drowning
Other
Tier 3: How many are reached through those activities?
# receiving TA
# receiving professional/organizational development training
# of peer-reviewed publications published
# receiving information and education through outreach
# referred/ managed
% using fatality review data
See data collection form.
Tier 4: What are the related outcomes in the reporting year?
Rate of injury-related hospitalization to children ages 1-9.
Numerator: Injury-related hospitalizations to children
ages 1-9.
Denominator: Children ages 1-9 in the target
population.
Target Population: __________________________
Percent of children ages 6-11 missing 5 or more days of
school because of illness or injury.
Numerator: # of children ages 6-11 missing 5 or more
days of school.
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 37
CH 4 PERFORMANCE MEASURE
Goal: Injury Prevention
Level: Grantee
Domain: Child Health
The percent of programs promoting and/ or facilitating injury
prevention among children.
Denominator: Total number of children ages 6-11
represented in National Survey of Children’s Health
results. Dataset reporting from: ___________________
BENCHMARK DATA SOURCES
Related to HP2030 IVP-02: Reduce emergency department (ED)
visits for nonfatal injuries. (Baseline: 9,349.5 ED visits per
100,000 population in 2017 (age adjusted to the year 2000
standard population), Target: 7,738.2 ED visits per 100,000
population).
GRANTEE DATA SOURCES
Title V National Performance Measure #7 Child Injury, AHRQ
Healthcare Cost and Utilization Project: National Inpatient
Sample or State Inpatient Database; National Survey of
Children’s Health, Question G1 in the 6-11 year old survey
SIGNIFICANCE
Unintential injury is the leading cause of child and adolescent
mortality, from age 1 through 19.
6
Homicide and suicide, violent
or intentional injury, are the second and third leading causes of
death for adolescents ages 15 through 19.
4
The total death rate
for persons aged 10-19 years decreased 33% between 1999 and
2013, then increased 12% between 2013 and 2016 due to an
increase in injury deaths.
7
For those who suffer non-fatal severe
injuries, many will become children with special health care
needs. Effective interventions to reduce injury exist but are not
fully implemented in systems of care that serve children and their
families. Reducing the burden of nonfatal injury can greatly
improve the life course trajectory of infants, children, and
adolescents resulting in improved quality of life and cost savings.
6
Heron M. Deaths: Leading Causes for 2017. National Vital Statistics Reports. 2019 June 24. 68(6).
https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf
7
Curtin SC, Heron M, Minino AM, Warner M. Recent Increases in Injury Mortality Among Children and Adolescents Aged 10-19
years in the United States: 1999-2016. National Vital Statistics Reports. 67 (4)
https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_04.pdf.
OMB Number: 0915-0298
Expiration Date: 8/31/2025
Attachment B | 38
Data Collection Form for Detail Sheet # CH 4
Please use the form below to report what services you provided in which safety domains, and how many recipients received those services. Please use the space provided for
notes to specify the recipients of each type of service.
Motor
Vehicle
Traffic
Suicide/
Self-
Harm
Falls Bullying
Child
Maltreatment
Unintentional
Poisoning
Prescription
drug
overdose
Traumatic
Brain
Injury
Drowning
Other
(Specify)
Technical Assistance
Training
Research/
dissemination
Peer-reviewed
publications
Outreach/
Information
Dissemination/
Education
Referral/ care
coordination
Quality improvement
initiatives
Use of fatality review
data
Notes: