Illinois Department of Human Services s3

ILLINOIS DEPARTMENT OF HUMAN SERVICES

MATERNAL, INFANT, & EARLY CHILDHOOD HOME VISITING (MIECHV) PROGRAM

Coordinated Intake Quarterly Report for State Fiscal Year 2017 (Revised 8/8/16)
Please indicate the quarter for which you are reporting:
1st Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter
July, Aug, Sept
Due: 10/15/16 / Oct, Nov, Dec
Due: 01/30/2017 / Jan, Feb, March
Due: 04/15/2017 / April, May, June
Due: 07/15/2017

MIECHV COORDINATED INTAKE SITE INFORMATION

MIECHV Community:
Agency Name:
Program Contact:
Phone Number:
E-Mail Address:
1. / Home Visiting Referrals, Engagement, and Caseload Capacity
a. / Please attach your most recent monthly CI referral tracking form and your community’s Visit Tracker report from Wayne Fish.
b. / Any comments or concerns about the data in these forms/reports?
c. / To what extent is your community’s HV caseload currently full? (Please provide a percentage.) / %
d. / If your community’s caseload is not full, please describe the challenges or barriers involved and your strategy for addressing these.
e. / Describe any challenges in using the Coordinated Intake function in Visit Tracker, along with any suggestions for improvement.
2. / Coordinated Intake Activities: Please briefly describe:
a. / How is your program assisting uninsured home visiting families in enrolling for health insurance? (This is one of the MIECHV benchmarks.) Are there any barriers that your families are experiencing?
b. / During this quarter, what have been the most successful activities for recruiting families or increasing community awareness regarding the benefits of home visiting?
c. / Other activities, such as special events, designed to increase community awareness of the benefits of home visiting or the number of referrals to home visiting.
d. / Any additional new initiatives during this quarter, including anticipated outcomes.
e. / Participant or program success stories.
3. / Program Operations: Please briefly describe:
a. / Any current successes and/or challenges related to coordination with HV agencies.
b. / Any current successes and/or challenges related to CQI (led by CPRD).
c. / Any barriers that have affected coordinated intake. If resolved, include strategies used.
d. / Any program assistance needed from the MIECHV State Team, including any training needs. Please be as specific as possible.
e. / One suggested change or improvement at the State level that would make your work easier.
4. / MIECHV Staffing
List all MIECHV Coordinated Intake Workers who were employed during the reporting period / Hire Date / Exit Date (N/A if still employed) / % FTE for MIECHV
List MIECHV Coordinated Intake Supervisors who were employed during the reporting period
List “Other” Coordinated Intake MIECHV Staff below (please include title) who were employed during the time period
4. / Staff Recruitment and Retention
Column A / Column B / Column C / Column D / Column E / Column F / Column G / Column H / Column I
Number of New FTE MIECHV CI Workers / Number of Continuing FTE MIECHV CI Workers / Number of FTE MIECHV CI Workers (A+B) / Number of New FTE MIECHV CI Supervisors / Number of Continuing FTE CI Supervisors / Number of FTE MIECHV CI Supervisors (D+E) / Number of New FTE MIECHV CI Other Staff / Number of Continuing FTE MIECHV CI Other Staff / Number of FTE MIECHV CI Other Staff (G+H)
5. / Staff Vacancies
Column A / Column B / Column C / Column D
Number of Vacant FTE MIECHV CI Workers / Number of Vacant FTE MIECHV CI Supervisors / Number of Vacant FTE MIECHV CI Other Staff / Number of FTE MIECHV CI Staff Vacancies (A+B+C)
OPTIONAL: Please include any additional questions, comments or suggestions:

Please email your completed report to: . Thanks!