Skip to main content

Oregon State Flag An official website of the State of Oregon »

Oregon Health Authority

Appendices

Appendix A: Client Enrollment
Appendix B: Client Support
Appendix C: Orientation Checklist 
Appendix D: Community Health Worker Role
Appendix E: Supervisory Support Material
Appendix F: Client Bill of Rights
Appendix G: Documentation Checklists
Appendix H: Basecamp Instructions

References

Please let us know if you have suggestions, any links are broken, or if any information is outdated. 
Babies First! and CaCoon Manual Feedback Form

Appendix A: Client Enrollment

Download Appendix A: Client Enrollment.pdf

Many factors influence whether an eligible person or families will enroll in home visiting services. These include things like trust, functional status and parenting confidence, as well as age, race, education and mental health history. Provider and community-level factors also influence enrollment, including strength of relationships between providers and home visiting program, level of follow-up for hard-to-reach families, and level of poverty. Below are some ideas to help support conversion of referrals to enrollment at the client, provider, and community level.

Client Level

  • Conduct follow up in a timely manner (within 2 days of receiving referral is optimal; required within 10 days).
  • Engage in relationship-building techniques at first contact: create time to listen and add open-ended questions related to what the client has heard about Babies First!, and what they are feeling about their pregnancy or their baby (if enrolling after baby is born) and what the person desires for themselves and their baby.
  • Highlight the program in terms of what it can do for the mother or caregiver.
  • Develop a program “pitch" that stresses program flexibility. Some things to consider:
    • » An opening statement that makes it clear you are open to meeting them wherever they feel comfortable: “I'd love to talk to you about the things you interested in about [becoming a mom, about your baby, taking care of your child]. We do visits in the home – or wherever works for you". »
    • An overview of program, stressing that the schedule and place can be “whatever works best for you" and that it is no cost to the client.
    • Provide the pitch in-person in a safe environment (e.g., waiting room area).
  • Ensure potential client that you would not approach them in public unless they say it's okay (e.g., if a pregnant parent, they may not have told people about the pregnancy).
  • If over the phone, make the focus more about listening to the potential client and what they are interested in (the open-ended questions are good to help facilitate this).
  • End the call with a promise to call or have a meeting time set and normalize that people need to think about this. E.g., “Some people need a little time to think about whether they would like a program like this. May I call you next week to talk about what you want to do?"
  • Be willing to follow up with further outreach (e.g., a letter and subsequent phone call).

Provider Level

  • Doing outreach to providers can be helpful because if a client hears their provider talking positively about the program, they may be more willing to engage. Some outreach to provider ideas:
    • Ask to present about the program at provider staff meetings.
    • Develop contact person at provider offices who you can follow up with about referrals.
    • Bring information sheets, brochures about program to leave at provider offices.
    • Create “office time" at a provider office on a regular basis so you can be there to engage directly with potential clients and be a known entity.

Community Level

Promote community acceptance by:

  • Encouraging community engagement (e.g., Community Advisory Boards)
  • Outreach to multiple types of referral agencies (e.g., WIC, Schools, Pediatric or OB Clinics, Hospital)
  • Connecting with early childhood education programs

References

Damashek, A., Doughty, D., Ware, L., & Silovsky, J. (2011). Predictors of client engagement and attrition in home-based child maltreatment prevention services. Child Maltreatment, (16)1, 9-20. Doi: 10.177/1077559510388507

Folger AT, Brentley AL, Goyal NK, et al. Evaluation of a Community-Based Approach to Strengthen Retention in Early Childhood Home Visiting. Prev Sci. 2016;17(1):52-61.

Goyal NK, Hall ES, Jones DE, et al. Association of maternal and community factors with enrollment in home visiting among at-risk, first-time mothers. Am J Public Health. 2014;104 Suppl 1(Suppl 1):S144-51.

Home Visiting and Community-Based Partners: Innovative Strategies for Engaging Hard-to-Reach Populations. https://www.mdrc.org/home-visitingand-community- based-partners, accessed 10/1/2021.

Issue Brief: Engaging Families in Home Visiting. Institute for Child and Family Well- Being. April 29, 2016. https://uwm.edu/icfw/engaging/ accessed 2/14/2019.

Appendix B: Client Support

Download Appendix B:Client Support.pdf

How Can Your Nurse Support You?



I would like support for: 

  • Getting Medicaid/WIC/Food Stamps
  • Scheduling pregnancy appointments
  • Accessing transportation
  • Finding affordable/nutritious food
  • Finding stable housing
  • Finding a counselor
  • Lowering my stress
  • Working to quit smoking
  • Finding drug or alcohol treatment
  • Dealing with an abusive relationship
  • Finding resources for my other children
  • Setting goals for myself/my family
  • Other: 

I would like to find:

  • Doula or pregnancy support
  • Childbirth or Lamaze classes
  • Baby supplies
  • Job-seeking support
  • English As A Second Language classes
  • Childcare
  • Playgroups
  • Support groups for moms
  • Other:  

I wish I knew more about: 

  • What to expect during pregnancy
  • What to eat during pregnancy
    Making a birth plan
  • Labor and Delivery
  • How my baby grows and learns
  • Baby care
  • Birth control and family planning
  • Breastfeeding
  • Healthy relationships
  • Reducing stress
  • Child support
  • Immunizations
  • Making my home safe for my baby
  • Other

Everything is okay right now, but I would like:

  • Someone to check on the progress of my pregnancy
  • Someone to check on my baby's development
  • Someone to talk to
  • Other


Appendix C: Orientation Checklist

Download Appendix C: Orientation Checklist

Public Health Home Visitor Orientation Checklist

Hello and welcome to Nurse Home Visiting in Oregon!

This document is meant to help guide you as you begin your role as a home visitor for the Babies First! and/or CaCoon program(s). During the first month, it is recommended that you focus solely on orientating to the program(s). Do not plan on taking on any clients during your first month.

There is a lot of information throughout this orientation, be kind to yourself and take it slow. Ask questions when you have them.

The first month has the most learning to complete: we recommend not enrolling clients on your caseload during this time. Month two and month three will build on the first month orientation.

Remember that learning does not stop after you complete this checklist. Plan regular and reoccurring time in your schedule to stay up to date on best practice, and plan to attend the monthly community of practice meetings.

Home visiting is important work that can change the course of a life. We are excited to have you as part of the team and we thank you for making a commitment to children and families in Oregon!

Nurse Home Visitor Client Encounter Ramp Up Schedule Example

The actual number of visits per week/month during ramp up will depend on experience of the nurse, training needed, whether visits are done virtually or in-person, and whether the new nurse takes on an existing caseload or is building a new caseload. The below example assumes a new nurse that must build their caseload from zero and who conducts all visits in-person. 

Return to top

Appendix D: Community Health Care Worker Role

Download Appendix D: Community Health Worker Role
Babies First! and CaCoon are public health nurse (PHN) home visiting programs. Non-nurse professionals may provide services within these programs including interpretation, data entry, administrative support, and home visiting services. This document will provide a guideline specifically for the role of the non-nurse home visitor. While a variety of terms have been used to describe the non-nurse home visitor role in the past, the current recommendation is to define the role as a Community Health Worker (CHW) and to adhere to the guidance provided for job description, competency validation, and TCM billing. 

This document will serve as a guide for how the PHN and CHW should work together to provide services to families. Other roles may continue to exist in a PHN home visiting program, but the role of non-nurse home visitor in the Babies First! or CaCoon program should align with this guideline. 

Babies First! and CaCoon CHW Job Description

A CHW is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.

The CHW:

  1. Has expertise or experience in public health;
  2. Works in an urban or rural community, either for pay or as a volunteer in association with a local health care system;
  3. To the extent practicable, shares ethnicity, language, socioeconomic status and life experiences with the residents of the community where the worker serves;
  4. Assists members of the community to improve their health and increases the capacity of the community to meet the health care needs of its residents and achieve wellness;
  5. Provides health education and information that is culturally appropriate to the individuals being served;
  6. Assists community residents in receiving the care they need. (e.g. may give peer counseling and guidance on health behaviors, and
  7. May provide direct services such as first aid or blood pressure screening (if competency validated (see below).  

CHW Certification is not required for CHWs working in the Babies First! or CaCoon program at this time, but it is recommended. Certification provides a standard of professional excellence and accountability. Information about certification can be found at the OHA Community Health Worker site. A bill for Targeted Case Management (TCM) services may be submitted for a visit provided by the CHW, if the visit activities meet the requirements outlined in the TCM Rules. Please see Targeted Case Management section for more details. The following description of the minimum qualifications for the non-nurse home visitor role from the TCM rules should be taken into consideration when creating a job description for the CHW in the Babies First! or CaCoon programs. The TCM rule (OAR 410-138-0060) defines the minimum qualifications for a CHW providing TCM services in a PHN home visiting program as follows:

  1. High School graduate or GED
  2. Two years' experience in public health, mental health, or alcohol drug treatment settings
  3.  Any satisfactory combination of experience and training that demonstrates the ability to perform case management services
  4. Must work under the policies, procedures, and protocols of the state MCH Program. 

Training and Competency Validation

The Core Competencies specific to the CHW role are:

  1. Outreach and mobilization
  2. Community and Cultural Liaising
  3. Case Management
  4. Care Coordination
  5. System Navigation
  6. Health Promotion and Coaching

It is the responsibility of the local implementing agency to ensure CHWs are educated and competency validated to perform the responsibilities of their position within the respective organization. It is also the responsibility of the local implementing agency to ensure the work of the CHW is adequately supervised.

A variety of methods may be used to validate competencies. The local implementing agency should consider validating competencies upon hire and yearly thereafter. For the yearly competency validation, the supervisor may choose to use the yearly chart review and observation of a home visit as a time to validate competency. Local implementing agencies might also consider a yearly skills fair for more tactile skills like blood pressuring screening or newborn weight checks. 

The following tools are available in the Babies First! and CaCoon manual to assess learning needs, guide orientation, and validate competencies: 

Nurse Home-Visiting: Nursing Process and Assignment of Care

Public Health Nurses (PHN) in the Babies First! and CaCoon programs are required to be Registered Nurses. The term PHN will be used to describe the role of the Registered Nurse practicing nursing within the Babies First! and CaCoon programs. The Nurse Practice Act provides guidance for the RN's responsibility for nursing practice. Before we can understand the role of assignment to the CHW, we must understand the nursing process. The PHN is responsible to use the nursing process in their care of the client. The PHN conducts a comprehensive assessment and develops reasoned conclusions which identify client problems or risks. The PHN then develops an individualized nursing plan of care for the client. As the PHN develops their nursing plan of care, they take into consideration the condition of the client and how to administer the nursing plan of care. The PHN may then assign aspects of the nursing plan of care to a CHW as per their nursing judgment.

The nursing plan of care is not the same as the TCM care plan, and the nurse and client should work together to create the TCM care plan. For information about the requirements around the TCM care plan, please see Chapter 4 of the Babies First! manual. Regardless of how they decide to administer the nursing plan of care (independently or by assignment to CHW), the complete nursing process must be followed.

The PHN is responsible to evaluate the client's responses to the nursing interventions and their progress toward identified outcomes. The nursing plan of care is then updated or modified by the PHN based on ongoing client assessment and evaluation of data. 

Assignment to the CHW

In the Babies First! and CaCoon programs, the CHW is a trained, competency validated, and professional home visitor. In this context, the relationship between the PHN and the CHW is one of assignment of aspects of the nursing plan of care, not one of delegation of specific tasks. Care should be taken to follow the Nurse Practice Act's guidance on assignment of care.

The PHN assigns activities within the CHW competencies as per their job description and ensures accountability to the individualized nursing plan of care for the client. As stated previously, it is the responsibility of the local implementing agency to ensure that CHWs are prepared and competency validated to perform the responsibilities of their position within the respective organization. It is the responsibility of the PHN to know which activities may be performed by the CHW under their job description and to use the nursing process and critical thinking to discern if an assignment to a CHW is appropriate for the client. The nurse supervises the activities assigned to the CHW in the nursing plan of care. The local implementing agency is responsible to supervise the individual.

When making an assignment to the CHW, the PHN is also responsible to ensure documentation of the activity by the CHW and to evaluate the effectiveness of the assignment. In the Babies First! and CaCoon programs, the PHN must review and sign CHW documentation in the chart and in any TCM specific documentation within a specific time frame defined by the local implementing agency.

The PHN is also responsible for periodically reassessing the client in person to determine if the client's needs or preferences have changed. This in-person reassessment shall be conducted at least every 3 months or more frequently if changes occur in the client's condition. In order to ascertain the need for a more frequent reassessment, the PHN must review documentation notes after each home visit (as noted above) and be in regular communication with the CHW regarding their interactions with the client. 

1. Can a CHW administer a screening such as PSQ-9 or ASQ?

For the PHN to assign a screening such as PSQ-9 or ASQ to the CHW, the CHW must first be competency validated in that skill. In addition, when the PHN develops the plan for the CHW to administer the screening, they must carefully consider the screening tool. If the screening tool provides clear guidance about how to follow-up, the CHW may complete the screening independently, document their findings, and follow-up accordingly. If the PHN observes that the tool asks for judgment to be exercised regarding how to discern the appropriate next steps, the PHN should either provide clear parameters for when the CHW must report back to the PHN and/or clear parameters to help the CHW determine the appropriate next steps. ​

2. Can the CHW provide direct services such as blood pressure screening or height/ weight?

The role description above notes that the CHW may provide some direct services such as first aid or blood pressure screening. If the PHN determines it is appropriate given the client's condition, the PHN may assign BP screening to the CHW provided that the CHW is competency validated in that skill. When the PHN develops the nursing plan of care, they must define specific parameters regarding follow-up steps and when the CHW should report back to the PHN. ​

3. May we rename our administrative staff role to “CHW”?

No. Other roles may continue to exist in a PHN home visiting program, including administrative and other support staff. The role of the non-nurse home visitor in the Babies First! or CaCoon programs should be defined as a CHW if they are providing home visiting services.​

4. Is my nursing license on the line for CHW activities?
The CHW does not work “under the license" of the PHN. The CHW works for the local implementing agency to which they have been hired and the local implementing agency is responsible for their training and competency validation. The PHN is accountable to the nursing plan of care they create. The PHN must use their nursing judgment ensure that any assignment is appropriate for the CHW role given the client's specific condition. The PHN must provide appropriate parameters for follow-up if necessary. 
5. Should the CHW submit THEO data for their visit?

​Yes. The CHW must submit THEO data for any home visiting service just as the PHN would.

​6. Can CHWs be used as interpreters?
While a CHW may provide interpretation services, a CHW and an interpreter are not interchangeable. Each role has distinct sets of competencies and skills and some individuals may have both. If a CHW will provide interpretation services, consider appropriate training and compensation. Interpretation services are not considered TCM billable. 

References

1. American Public Health Association. (2020). Community Health Workers. Retrieved from https://www.apha.org/apha-communities/member-sections/community-healthworkers.

2. Oregon Revised Statues (ORS) 414.025, 2020. Retrieved from https://www. oregonlegislature.gov/bills_laws/ors/ors414.html

3. Oregon Administrative Rules (OAR) 410-138-0060. Retrieved from https://secure.sos. state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=268911 60

4. Oregon Health Policy Board. (n.d.). The role of non-traditional health workers in Oregon's health care system. Retrieved from https://www.oregon.gov/oha/oei/ Documents/nthw-report-120106.pdf.

5. Meeting with Ruby Jason, MSN, RN, NEA-BC, Executive Director of Oregon State Board of Nursing on March 9, 2020.

6. Oregon Administrative Rules (OAR) 851-045-0060. Retrieved from https://secure.sos. state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=216346

7. Oregon State Board of Nursing. (2019). Oregon State Board of Nursing interpretive statement: “Delegation process" and “assignment and supervision". Retrieved from https://www.oregon.gov/osbn/Documents/IS_Delegation_Assignment_Supervision. pdf.

Return to top

Appendix E: Supervisory Support Material

MCH Home Visiting Supervision Meeting Documentation Form

This is a sample of a generic supervision form that could be used to document and track meetings between a supervisors and home visitor. Consider how this information can be shared between the supervisor and home visitor. 

Download Supervision Meeting Documentation Form

Return to top

Appendix F: Client Bill of Rights

Click to download printable PDF versions. 

  1. Demographic and Service Coordination Checklist
  2. Nursing Documentation Checklist.pdf
  3. CHW Documentation Checklist.pdf
  4. TCM Document Checklist.pdf 
  5. Combined Document Checklist
    • TCM documents are located in Basecamp, Docs & Files, TCM folder


Return to top

Appendix H: Basecamp Instructions

Use of Basecamp for Nurse Home Visiting Programs

Basecamp provides an online platform for the sharing of resources and documents as well as fostering a community of support with home visitors and supervisors across the state. The platform provides a unique opportunity to ask each other questions and share tools, resources and documents. This supports peer learning and the ability for home visitors and supervisors to “share seamlessly and steal shamelessly" with each other across the state. Please note that shared documents have been voluntarily offered by different counties as example documents. They have not all been vetted by state nurse consultants.

*Do not post any client identifiable information anywhere in Basecamp. The goal of Basecamp is to share resources and to find support across counties. Any disclosure of information which could potentially identify a client is strictly prohibited.

Technical Requirements for Using Basecamp

Basecamp works everywhere you do. Just sign in with your desktop, phone or tablet web browser, or download the free apps for Windows, Mac, iOS and Android. Basecamp is available anywhere you have an internet connection. If you are not sure if you have the right browser, check the Basecamp System Requirements for All.

Basecamp Access

Send an email to your state nurse consultant to request a Basecamp invitation. The full user guidance is located on Basecamp under Docs and Files: Basecamp Info.

Return to top

References

  1. Kruger, B. (2004). Care Coordination. In P. Jackson Allen & J. Vessey (eds.), Primary Care of the Child with a Chronic Condition (4th ed.). St. Louis, MO: Mosby.
  2. Oh, Hans and Lee, Christina. Culture and Motivational Interviewing. Patient Educ Couns. 2016 November; 99(11): 1914–1919. doi:10.1016/j.pec.2016.06.0                
  3. Venner KL, Greenfield B, Hagler K, Simmons J, Lupee D, et al. Pilot outcome results of culturally adapted evidence-based substance use disorder treatment with a Southwest Tribe. Addictive Behaviors Reports. 2016;(3): 21–27.
  4. First Nations Health Authority [Internet]. Cultural Safety and Humility Key Drivers and Ideas for Change; c2024 [cited 2024 February]. Available from: https://www.fnha.ca/Documents/FNHA-Cultural-Safety-and-Humility-Key-Drivers-and-Ideas-for-Change.pdf
  5. Hockenberry, M. Wong's Essentials of Pediatric Nursing. 7th ed. St. Louis: Mosby (2004).
  6. United Spinal Association [Internet].  Disability Etiquette Guide; c2020 [cited 2024 February]. Available from: https://www.unitedspinal.org/pdf/DisabilityEtiquette.pdf?_gl=1*1pmxv83*_ga*MTI1OTAwNzAyNS4xNzAxMzg5NDgz*_ga_ZS2Q737YSD*MTcwMTM4OTQ4My4xLjEuMTcwMTM4OTUxMy4zMC4wLjA.
  7. Minnesota Department of Health [Internet]. Reflective Practice in Home Visiting; c2024 [cited 2024 February]. Available from: https://www2cdn.web.health.state.mn.us/communities/fhv/refpract.html
  8. Hopkins Medicine [Internet]. Evidence Based Practice; c2024 [cited 2024 February]. Available from: https://www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursing-inquiry/evidence-based-practice
  9. Bradley.edu [Internet]. How does evidence-based practice differ from evidence-informed practice; [cited 2024 February]. Available from: https://onlinedegrees.bradley.edu/blog/how-does-evidence-based-practice-differ-from-evidence-informed-practice/
  10. Pew Charitable Trusts [Internet]. Family Support and Coaching Program; c2015 [cited 2024 February]. Available from: https://www.pewtrusts.org/~/media/assets/2015/10/hvmessagingbrief.pdf
  11. Powell C, Grantham-McGregor S. Home visiting of varying frequency and child development. Pediatrics. 1989 Jul;84(1):157-64. PMID: 2740166.
  12. Association of Maternal and Child Health Programs [Internet]. Facilitating Attuned Interactions; c2020 [cited 2024 February]. Available from: https://amchp.org/2020/02/15/facilitating-attuned-interactions-fan/
  13. Agency for Healthcare Research and Policy [Internet]. Care Coordination; c2018 [cited 2024 February]. Available from: https://www.ahrq.gov/ncepcr/care/coordination.html#:~:text=Care%20coordination%20involves%20deliberately%20organizing,safer%20and%20more%20effective%20care.
  14. Minnesota Department of Health [Internet]. Public health interventions: Applications for public health nursing practice (2nd ed.); c2019 [cited 2024 February]. Available from: https://www.health.state.mn.us/communities/practice/research/phncouncil/docs/PHInterventions.pdf
  15. Healthy Outcomes from Positive Experiences [Internet]. HOPE-informed screenings and assessments; c2023 [cited 2024 February]. Available from: https://positiveexperience.org/wp-content/uploads/2023/08/HOPE-informed-screenings-and-assesment.pdf
  16. Kumah EA, McSherry R, Bettany-Saltikov J, van Schaik P, Hamilton S, Hogg J, et al. Evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of UG student. Campbell Syst Rev. 2022 Apr 16;18(2):e1233. doi: 10.1002/cl2.1233. PMID: 36911346; PMCID: PMC9013402.

Please let us know if you have suggestions, any links are broken, or if any information is outdated. 
Babies First! and CaCoon Manual Feedback Form