DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Prevention Services Division NURSE HOME VISITOR PROGRAM 6 CCR 1016-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________

1.1 Definitions.

(1) “Alternative Nurse Home Visitation Program” means a program that provides home visits by nurses but is not the program described in §25-31-104(1), C.R.S., but does qualify for funding from the Nurse Home Visitor Fund because it meets the requirements of §25-31-104(4), C.R.S. and §1.10 of these rules.

(2) “Board” means the State Board of Health.

(3) “Conflict of interest” means a personal or financial interest that could reasonably be perceived as an interest that may influence an individual in his or her official duties.

(4) “Department” means the Department of Public Health and Environment.

(5) “Entity” means any nonprofit, not-for-profit, or for-profit corporation, religious or charitable organization, institution of higher education, visiting nurse association, existing visiting nurse program, local health department, county department of social services, political subdivision of the state, or other governmental agency or any combination thereof.

(6) “Expansion Site” means a program that is already serving at least one -hundred low-income, first-time mothers, through a grant received under these rules, in the previous fiscal year, and the implementing entity is applying for additional funding to enable it to serve additional low-income, first-time mothers.

(7) “Financial Interest” means a substantial interest held by an individual which is an ownership or vested interest in an entity, or employment or a prospective employment for which negotiations have begun, or a directorship or officership in an entity.

(8) “Health Sciences Facility” means a facility located at the University of Colorado Health Sciences Center that is selected by the President of the University of Colorado.

(9) “Low-income” means an annual income that does not exceed two hundred percent of the federal poverty level.

(10) “New Entity” means any entity that has not previously received funding for the program pursuant to these rules.

(11) “Nurse” means a person licensed as a professional nurse pursuant to §12-38-102, C.R.S., et seq., or accredited by another state or voluntary agency that the state board of nursing has identified by rule pursuant to §12-38-108(l)(a), C.R.S., as one whose accreditation may be accepted in lieu of board approval.

Code of Colorado Regulations 1 (12) “Nurse Home Visitor Program” or “Program” means a program that is described in §25-31-104(1), C.R.S., and meets the requirements of these rules.

(13) “Nurse Supervisor” means a nurse with a master's degree in nursing or public health, unless the implementing entity can demonstrate that such a person is either unavailable within the community or an appropriately qualified nurse without a master's degree is available.

(14) “Visit Protocols” mean nurse home visit guidelines addressing, at a minimum, prenatal, infancy and toddler development and cover topics such as positive birth outcomes, parental life course development and parenting skills.

1.2 Procedures for Grant Application.

(1) Grant Application Contents.

(a) General. All applications shall be submitted to the department by entities as defined in §1.1(5) in accordance with these rules and shall contain, at a minimum, the following information:

1. (i) A description of the specific training to be received by each nurse employed by the applicant to provide home visiting nursing services through the program, which training shall include, at a minimum, the training required in §1.6(1);
2. (ii) A description of the protocols to be followed by the applicant in administering the program, which protocols shall, at a minimum, comply with the requirements of §1.6(2);
3. (iii) A description of the management information system to be used by the applicant in administering the program, which system shall, at a minimum, comply with the requirements in § 1.6(3);
4. (iv) A description of the reporting and evaluation system to be used by the applicant in measuring the effectiveness of the program in assisting low-income, first-time mothers, which shall, at a minimum, comply with the requirements in §1.6(4);
5. (v) A budget which includes, at a minimum, each of the following:
   1. (A) Salaries and benefits for the staff required in §1.7;
   2. (B) Costs of the training provided by the Health Sciences Facility, and costs to cover any other training required by the Health Sciences Facility. Allowable costs include but are not limited to, travel costs and training materials;
   3. (C) Costs to purchase and maintain the management information system and related technical assistance;
   4. (D) Operating costs, including but not limited to, office and program supplies, postage, telephones, computer(s) with internet access, liability insurance, medical supplies, mileage reimbursement and other staff development for the required staff;
   5. (E) A description of how the applicant will fund any additional costs not funded by the grant;

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1. (F) Any in-kind contributions the applicant or other stakeholders in the community may donate.

(b) Applications for New Entities. In addition to the requirements of § 1.2 (a) of these rules, applications for new entities shall contain, at a minimum, the following information:

1. (i) A description of the experience the applicant has working with the target population and existing home visitation programs;
2. (ii) A description of the community support for the program and for the applicant as the lead organization in its implementation, including detailed information about the broad based support for the program's implementation. Breadth of community support shall be judged by the diversity of those involved in supporting the program's implementation, and can be evidenced through letters of support and more formal referral relationships among various community organizations and the applicant;
3. (iii) A description of the specific needs of the population to be served, including but not limited to, the socio-demographic and health characteristics that justify the need for the program and the number of first-time, low-income mothers eligible for the program;
4. (iv) A description of the relationship of the applicant with the schools, prenatal clinics and other referral sources for the first-time, low-income mothers who will be served by the program, with specific information about the duration of these relationships;
5. (v) A description of the nature and duration of the referral linkages that exist between the applicant and other service providers throughout the community, including but not limited to, providers of social services, mental health services, workforce preparation services, job training services, legal services, health care services and child care services;
6. (vi) Except as provided in § 1.9, a description of a plan for recruiting at least one hundred first-time, low-income mothers;
7. (vii) A description of the collaboration between the applicant and other entities providing similar services to the same population, including plans for coordination and a description of how the program will fit in with and complement the community's efforts to meet the needs of the target population, if applicable;
8. (viii) A plan for hiring and retaining qualified staff that represents the community's racial and cultural diversity;
9. (ix) A description of the applicant's capacity to comply with and monitor the implementation of the grant requirements;
10. (x) Summary of the major strengths of the applicant and the community that will lead to successful implementation of the program; and (xi) A statement as to whether the applicant plans to work collaboratively with other entities in either administering the program or through an oversight board, and whether the other entities are other counties, municipalities, agencies or organizations.

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1. (xi) If an applicant currently provides services in compliance with §§ 1.6 through 1.9(1) using funding other than from the Nurse Home Visitor Program Fund, the applicant shall:
   1. (A) State whether the applicant expects to continue to receive funding from such alternative funding source; and (B) State whether the funds received pursuant to these rules will be used to increase the number of clients served.

(c) Applications for Multiple Community Collaboration. If multiple communities with lower birth rates need to collaborate to meet the one hundred-family requirement, the applicant shall provide specific plans that address the mechanisms and history of the collaboration in addition to complying with the requirements of §1.2 (a) and (b). The plan shall include, but not be limited to, examples of previous collaborations.

(d) Applications for Expansion Sites. In addition to complying with the requirements of §1.2(1)(a), each expansion site shall submit the following in its application:

1. (i) Confirmation that the entity has implemented the program in compliance with these rules;
2. (ii) A description of additional community demand for the program that is not being met through the current funding;
3. (iii) A specific plan for building additional infrastructure to support the expansion of the program, including, but not limited to, physical space, staff supervision and computer data entry personnel;
4. (iv) A description of how the implementing entity has addressed previous specific challenges relating to the program;
5. (v) A plan describing the implementing entity's strategy to recruit and train sufficient qualified nurses to implement and expand the program; and (vi) A description of community support for the planned expansion of the program.

(2) Timelines for Grant Applications.

Grant applications may be solicited up to two times each fiscal year.

1.3 Review of Applications.

(1) The department shall conduct an initial review of submitted applications.

(2) After the department's initial review of the applications, the health sciences facility shall review the applications and shall submit to the board a list of entities that the health sciences facility recommends to administer the program in communities throughout the state.

1.4 Criteria for Selection of Entities.

(1) At a minimum, the following criteria shall be used for selecting potential grantees:

(a) The applicant meets the definition of an “entity” as defined in § 1.1; Code of Colorado Regulations 4 (b) The entity submits a completed application in accordance with, the requirements of § 1.2;

(c) The entity demonstrates the capacity and ability to adequately administer and implement the program;

(d) The entity demonstrates that it will comply with the requirements of §§1.6 through 1.8;

(e) The entity's geographic service area and/or the population it serves advances the implementation of the program in communities throughout the state; and (f) The entity is selected on a competitive basis.

(2) More than one entity may receive funding in a particular community if it can demonstrate in its application:

(a) Broad community support for the implementing entity;

(b) Existence of a sufficient number of eligible women to support multiple implementing entities;

(c) Existence of close coordination and mutual support between the entities; and (d) A specific plan for the coordination by the applying entity and other nurse home visitation programs in the community.

1.5 Awarding of Program Grants.

(1) The board shall award grants to the selected entities specifying the amount of the grant.

(2) The grant awards may, at a minimum, include monies to fund:

(a) Reasonable and necessary salaries and benefits for nurses, nurse supervisors and data entry employees;

(b) Reasonable and necessary operating costs, including but not limited to, medical, program and office supplies, telephones, computer equipment, mileage reimbursement, any required insurance, and staff development;

(c) Reasonable and necessary training, training materials and travel costs associated with obtaining training required by §1.6(1);

(d) Reasonable and necessary cost for purchasing the management information system, and any related technical assistance; and (e) Reasonable and necessary costs for developing any infrastructure necessary for program administration and implementation.

1.6 Program Requirements.

(1) Training Requirements. Each nurse employed by an entity to provide home visiting nursing services through the program shall be required, at a minimum, to attend and complete the following training:

(a) Up to five days preparatory training for prenatal visits which shall include training on the following topics:

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1. (i) program goals and theoretical underpinnings;
2. (ii) assessment of family strengths and risk factors;
3. (iii) relationships skills and principles for developing self-efficacy;
4. (iv) strategies for facilitating change in maternal health behaviors;
5. (v) orientation to the prenatal visit protocols; and (vi) orientation to the management information system and clinical recordkeeping.

(b) Up to four days preparatory training for infant visits which shall include training on the following topics:

1. (i) nurturing parent-infant attachment;
2. (ii) care of the baby; and (iii) use of infant visit protocols.

(c) Up to four days preparatory training for toddler visits which shall include training on the following topics:

1. (i) information on parenting issues;
2. (ii) achieving goals related to family economic self-sufficiency; and (iii) orientation to the toddler visit protocols.

(2) Visit protocols.

(a) The visit protocols followed by the entity in administering the program shall cover information specific to prenatal, infant and toddler phases. The visit protocols shall, at a minimum, address:

1. (i) the physical and emotional health of the mother and the baby, including for the mother information on the importance of nutrition and avoiding alcohol and drugs, including nicotine;
2. (ii) the environmental health issues such as ensuring a safe environment for the child;
3. (iii) the life course development for the mother, including employment, educational achievement, budgeting and financial planning, transportation and housing;
4. (iv) the parental role and responsibilities; and (v) the role of family and friends in supporting goal attainment.

(3) Program management information systems.

(a) The management information system used by the entity in administering and implementing the program shall, at a minimum, include the following:

1. (i) documentation of the services received by clients enrolled in the program; Code of Colorado Regulations 6 (ii) information to assist the program staff in tracking the progress of families in attaining program goals;
2. (iii) information to assist nurse supervisors in providing feedback to individual nurse home visitors on strengths and areas for improvement in implementing the program; and (iv) information to assist program staff in planning quality improvements to enhance program implementation and outcomes.

(4) Reporting and evaluation system.

(a) At least once every month, each implementing entity shall submit the data generated by the management information system required by §1.6(3) to the health sciences facility; and (b) The data will be analyzed and the health sciences facility shall make available, on no less than a quarterly basis, a report to the entity evaluating the program's implementation, and on a semi-annual basis shall also make available reports on benchmarks of program outcomes (c) The implementing entity shall submit an annual report that complies with the requirements in § 1.11 to both the health sciences facility and the community in which the entity implements the program that reports on the effectiveness of the program within the community.

(d) The annual report shall be submitted on or before March 1, or not later than sixty days after the end of the fiscal year for which funding was provided if the program has not submitted a request for continuation of funding. The annual report shall be written in a manner that is understandable for both the health sciences facility and members of the community that the program serves.

1.7 Staffing Requirements.

(1) For every one hundred low-income, first-time mothers enrolled in the program the program shall, at a minimum, have the following staff:

(a) Four full time equivalent (“FTE”) nurses;

(b) One half FTE nurse supervisor, and (c) One-half FTE data entry/clerical support person.

(2) The data entry/clerical support person shall provide office support to the nursing staff and assure data are submitted as required by §1.6 (3) and (4).

(3) The caseload for any one nurse at one time shall not exceed twenty-five low-income, first-time mothers.

1.8 Eligibility of Clients.

(1) At a minimum, the following is required to be eligible to receive program services:

(a) A woman with an annual income that does not exceed two hundred percent of the federal poverty level;

Code of Colorado Regulations 7 (b) No previous live births; and (c) Enrolled in the program during pregnancy or prior to the end of the first month of the baby's life.

(2) Preference will be given to women who enroll in the program prior to the 28th week of pregnancy.

1.9 Number of Clients Served -Waivers.

(1) Except as provided in §1.9(2), each entity shall provide services to a minimum of one hundred low- income, first-time mothers in the community in which the program is administered and implemented.

(2)

(a) If the population base of a community does not have the capacity to enroll one hundred eligible families, an entity may apply to the board for a waiver from this requirement.

(b) Prior to granting any waivers, the board shall consult with the health sciences facility to ensure that the entity can implement the program within a smaller community and comply with program requirements.

1.10 Availability of Funding for Alternative Nurse Home Visitation Programs.

(1) An alternative nurse home visitation program may qualify for funding under the nurse home visitor program if the alternative nurse home visitation program:

(a) Has been in operation in the state as of July 1, 1999 for a minimum of five years;

(b) Has achieved a significant reduction in each of the following:

1. (i) Infant behavioral impairments due to use of alcohol and other drugs, including nicotine;
2. (ii) The number of reported incidents of child abuse and neglect among families receiving services;
3. (iii) The number of subsequent pregnancies by mothers receiving services;
4. (iv) The receipt of public assistance by mothers receiving services; and (v) Criminal activity engaged in by mothers receiving services and their children.

(2) Any alternative nurse home visitation program qualifying for funding under this section shall be exempt from the requirements of § 1.6 if it continues to demonstrate significant reductions in the occurrences specified in §1.10 (1) (b).

(3) Any alternative nurse home visitation program qualifying for funding under this section shall comply with the requirements of § 1.11 of these rules.

1.11 Reporting Requirements for Tobacco Settlement Programs.

(1) All programs shall annually submit to the department a report which, at a minimum, includes the following information:

Code of Colorado Regulations 8 (a) The amount of tobacco settlement moneys received by the program for the preceding fiscal year;

(b) A description of the program, including the program goals, population served by the program, the actual number of people served, and the services provided; and (c) An evaluation of the operation of the program, which includes the effectiveness of the program in achieving its stated goals.

(2) Reports shall be submitted to the department no later than sixty days after the end of the fiscal year for which funding was provided.

1.12 Conflicts of Interest

(1) Applicability. Except as provided for in §§25-31-105, C.R.S. through 25-31-108, C.R.S. regarding the health sciences facility, this section applies to any person involved in:

(a) The review of completed applications;

(b) Making recommendations to the board regarding an entity that may receive a grant and the amount of said grant; or (c) Members of the board.

(2) Prohibited Behavior. No person who is involved in the activities specified in §1.12 (1) shall have a conflict of interest Such conflict of interest includes, but is not limited to, any conflict of interest involving the person and the grantee or the person and the tobacco industry.

(3) Responsibilities of Persons with a Potential Conflict of Interest A person who believes that he or she may have a conflict of interest shall disclose such conflict of interest as soon as he or she becomes aware of the conflict of interest. If the person is a member of the board and acting in the capacity of a board member, the person shall publicly disclose the conflict of interest to the board; other persons shall disclose the conflict of interest in writing to the department. If the board or the department, whichever is appropriate, determines the existence of a conflict of interest, the person shall recuse himself or herself from any of the activities specified in §1.12 (1) relating thereto.

1.13 Criteria for Reduction or Cessation of Funding.

(1) Upon recommendation from the health sciences facility, the board may reduce or eliminate the funding of a program if the entity is not operating the program in accordance with the program requirements established in §1.6 through §1.8, except as provided in §1.10 of these rules, or is operating the program in such a manner that it does not demonstrate positive results., (2) An entity shall receive written notification from the board if the entity's funding is subject to reduction or elimination.

_________________________________________________________________________ Editor’s Notes History Code of Colorado Regulations 9