Annual First 5 Fresno County Evaluation Report, 2005-2006 ... FFF 05-06 Annual Evaluation...Evaluation Report, 2005-2006 of the First 5 Fresno staff and providers A Report to the Children

Annual First 5 Fresno County Evaluation Report, 2005-2006

April 2007

LTG Associates, Inc.

A Report to the

Children and Families

Commission of Fresno County

Annual First 5 Fresno County

Evaluation Report, 2005-2006

A Report to the

Children and Families Commission

of Fresno County April 2007

Prepared by LTG Associates, Inc.

John Ogawa, Ph.D.

Karen Ito, Ph.D. Maribel Valencia Castillo. M.T.S.

Nathaniel Tashima, Ph.D. Kerry Weeda, M.A.A.

Michael French Smith, Ph.D. John Massad, Ph.D.

Acknowledgements LTG wishes to acknowledge the contributions of Brian Mimura, Planning and Evaluation Director of First 5 Fresno for his support and assistance. The assistance of Matthew Jones has been appreciated. Finally, our thanks to all of the First 5 Fresno staff and providers for their critical contributions.

i First 5 Fresno 05-06 Evaluation Report


Table of Contents

CHAPTER 1 BACKGROUND AND STRUCTURE OF THE REPORT......................................1 1.1 Background on First 5 Fresno’s Current Evaluation....................................................... 1 1.2 FY 2005-2006: Early Results from the New Framework ............................................... 1 1.3 First 5 Fresno Expenditure Overview for FY 05-06 ....................................................... 2 1.4 Service Overview ............................................................................................................ 5 1.5 Evaluation Approach....................................................................................................... 6 1.6 Sources of Data ............................................................................................................... 6 1.7 Structure of the Report .................................................................................................. 11

CHAPTER 2 DEMOGRAPHIC OVERVIEW .....................................................................13 2.1 Introduction ................................................................................................................... 13 2.2 Analyses Results ........................................................................................................... 13 2.3 Conclusions ................................................................................................................... 20

CHAPTER 3 PRIORITY AREA: EARLY CARE AND EDUCATION ....................................21 3.1 Introduction ................................................................................................................... 21 3.2 Area Overview .............................................................................................................. 21 3.3 Program Descriptions .................................................................................................... 26 3.4 Program Locations and Service Areas .......................................................................... 30 3.5 Process Evaluation ........................................................................................................ 35 3.6 Outcome Evaluation...................................................................................................... 40 3.7 Summary and Conclusions............................................................................................ 55

CHAPTER 4 PRIORITY AREA: HEALTH .......................................................................59 4.1 Introduction ................................................................................................................... 59 4.2 Area Overview .............................................................................................................. 60 4.3 Program Descriptions .................................................................................................... 61 4.4 Program Locations and Service Areas .......................................................................... 62 4.5 Process Evaluation ........................................................................................................ 62 4.6 Outcome Evaluation...................................................................................................... 68 4.7 Summary and Conclusions............................................................................................ 79

CHAPTER 5 PRIORITY AREA: CHILDREN WITH BEHAVIORAL, DEVELOPMENTAL, EMOTIONAL, MENTAL HEALTH, AND SPECIAL HEALTH NEEDS...........83

5.1 Introduction ................................................................................................................... 83 5.2 Area Overview .............................................................................................................. 84 5.3 Program Descriptions .................................................................................................... 86 5.4 Program Locations and Service Areas .......................................................................... 87 5.5 Process Evaluation ........................................................................................................ 92 5.6 Outcome Evaluation...................................................................................................... 95 5.7 Summary and Conclusions.......................................................................................... 109

ii First 5 Fresno 05-06 Evaluation Report LTG Associates, Inc.

CHAPTER 6 COMMUNITY-BASED INITIATIVES........................................................ 113 6.1 Community-Based Initiatives Overview..................................................................... 113 6.2 Program Locations and Service Areas ........................................................................ 113 6.3 Process Evaluation ...................................................................................................... 118 6.4 Outcome Evaluation.................................................................................................... 122 6.5 General Grants............................................................................................................. 122 6.6 Capital Grants.............................................................................................................. 124 6.7 Mini-Grants/Event Sponsorships ................................................................................ 125 6.8 Conclusion................................................................................................................... 128

CHAPTER 7 OVERARCHING PERSPECTIVES ............................................................. 131 7.1 Introduction ................................................................................................................. 131 7.2 Service Integration ...................................................................................................... 131 7.3 Accessibility of Services ............................................................................................. 132 7.4 Cultural/Linguistic Responsiveness ............................................................................ 133 7.5 Organizational and Provider Network Capacity ......................................................... 133 7.6 Long-term Impacts of First 5 Services ........................................................................ 134

iii First 5 Fresno 05-06 Evaluation Report


List of Tables

Table 1.1: Major LTG Accomplishments for First 5 Fresno:......................................................... 2 Table 1.2: First 5 Fresno Expenditure Summary for FY 05-06...................................................... 5 Table 1.3: First 5 Fresno Service Summary for FY 05-06 ............................................................. 6

Table 2.1: Age for Children 0-5 Served by First 5 Fresno in FY 05-06....................................... 14 Table 2.2: Gender for Children Served by First 5 Fresno in FY 05-06 ........................................ 14 Table 2.3: How many times you and your family moved in the last 12 months? ........................ 15 Table 2.4: How many family members in household including you? .......................................... 15 Table 2.5: Who is the child currently living with? ....................................................................... 15 Table 2.6: Which category best describes total family income in last year?................................ 16 Table 2.7: Ethnicity for Children and Parents Served by First 5 Fresno in FY 05-06.................. 17 Table 2.8: Language for Children and Parents Served by First 5 Fresno in FY 05-06 ................ 18 Table 2.9: Country of Birth for Children Served by First 5 Fresno in FY 05-06 ......................... 18 Table 2.10: What is the highest level of education completed by the child’s mother? ................ 19 Table 2.11: What is the highest level of education completed by the child’s father? .................. 19

Table 3.1: ECE Priority Area Program Listing and Expenditures................................................ 22 Table 3.2: ECE Priority Area, State Aggregate Data Form Summary ......................................... 35 Table 3.3: Community Strengthening Modality ........................................................................... 36 Table 3.4: Community Strengthening Topics............................................................................... 36 Table 3.5: Direct Services Unduplicated Counts and Service Contacts ....................................... 36 Table 3.6: Direct Services Service Contacts by Client Demographic .......................................... 37 Table 3.7: Direct Services Service Contacts by Modality ............................................................ 38 Table 3.8: Infrastructure Investment Activity............................................................................... 38 Table 3.9: Provider Capacity Building Service Contacts by Type of Client Served.................... 38 Table 3.10: Provider Capacity Building Training Topics............................................................. 39 Table 3.11: Systems Change Support Activity ............................................................................. 39 Table 3.12: Qualitative Data Collection Activities for PO 1 ........................................................ 41 Table 3.13: Qualitative Data Collection Activities for PO 2 and PO 3 ........................................ 45 Table 3.14: ASQ Scores for Children in PO 2 Programs ............................................................. 50 Table 3.15: ASQ Scores for Children in PO 3 Programs ............................................................. 51

Table 4.1: Health Priority Area Program Listing and Expenditures............................................. 60 Table 4.2: Health Priority Area, State Aggregate Data Form Summary ...................................... 65 Table 4.3: Community Strengthening Modality ........................................................................... 65 Table 4.4: Community Strengthening Topics............................................................................... 65 Table 4.5: Direct Services Unduplicated Counts and Service Contacts ....................................... 66 Table 4.6: Direct Services Service Contacts by Client Demographic .......................................... 66 Table 4.7: Direct Services Modality ............................................................................................. 67 Table 4.8: Provider Capacity Building Service Contacts by Type of Client Served.................... 67 Table 4.9: Provider Capacity Building Activity ........................................................................... 67 Table 4.10: Systems Change Support Activity ............................................................................. 68 Table 4.11: Healthy Kids Utilization in FY 05-06 ....................................................................... 70 Table 4.12: Qualitative Data Collection Activities for PO 4 and PO 5 ........................................ 70

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Table 5.1: Special Needs Priority Area Program Listing and Expenditures................................. 84 Table 5.2: Special Needs Priority Area, State Aggregate Data Form Summary .......................... 92 Table 5.3: Direct Services Unduplicated Counts and Service Contacts ....................................... 92 Table 5.4: Direct Services Service Contacts by Client Demographic .......................................... 93 Table 5.5: Direct Services Modality ............................................................................................. 94 Table 5.6: Infrastructure Investment Activity............................................................................... 94 Table 5.7: Provider Capacity Building Service Contacts by Type of Client Served.................... 94 Table 5.8: Provider Capacity Building Activity ........................................................................... 94 Table 5.9: Systems Change Support Activity ............................................................................... 95 Table 5.10: Qualitative Data Collection Activities for PO 8, 9 and 10 ........................................ 98 Table 5.11: ACC Diagnoses for Assessed Children ................................................................... 101 Table 5.12: ACC Client Satisfaction Data.................................................................................. 102 Table 5.13: ACC Referrers Data................................................................................................. 104

Table 6.1: Community-Based Initiatives, State Aggregate Data Form Summary...................... 118 Table 6.2: Community Strengthening Modality ......................................................................... 119 Table 6.3: Community Strengthening Topics............................................................................. 119 Table 6.4: Direct Services Unduplicated Counts and Service Contacts ..................................... 119 Table 6.5: Direct Services Service Contacts by Client Demographic ........................................ 120 Table 6.6: Direct Services Service Contacts by Modality .......................................................... 121 Table 6.7: Infrastructure Investment Activity............................................................................. 121 Table 6.8: Provider Capacity Building Service Contacts by Type of Client Served.................. 121 Table 6.9: Provider Capacity Building Training Topics............................................................. 121 Table 6.10: Systems Change Support Activity ........................................................................... 122 Table 6.11: Community-Based Initiative General Grants Program Listing and Expenditures .. 123 Table 6.12: Community-Based Initiative Capital Grants Program Listing and Expenditures ... 124 Table 6.13: Community-Based Initiative Mini-Grants & Event Sponsorships Program Listing

and Expenditures ...................................................................................................... 126

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List of Figures

Figure 1.1: FY 05-06 First 5 Fresno-Funded Program Locations .................................................. 3 Figure 1.2: Zip Codes Served by All First 5 Fresno Programs in FY 05-06 .................................. 4 Figure 1.3: Home Locations of Families Receiving Intensive Services: Fresno County ............... 8 Figure 1.4: Home Locations of Families Receiving Intensive Services: Fresno, Clovis, and

Sanger........................................................................................................................... 9

Figure 3.1: ECE Expenditure Distribution for FY 2005-2006 ..................................................... 23 Figure 3.2: Expenditure Distribution for School Readiness, Home Visitation and K-Camp

Programs FY 05-06 .................................................................................................... 25 Figure 3.3: Location of the ECE Priority Area Programs in FY 05-06 ........................................ 31 Figure 3.4: Zip Codes Served by ECE Priority Area Programs in FY 05-06............................... 32 Figure 3.5: Home Locations of Intensively-Served Families in ECE Priority Area Programs in

FY 05-06: Fresno County........................................................................................... 33 Figure 3.6: Home Locations of Intensively-Served Families in ECE Priority Area Programs in

FY 05-06: Fresno, Clovis, and Sanger ....................................................................... 34

Figure 4.1: Location of the Health Priority Area Programs in FY 05-06 ..................................... 63 Figure 4.2: Zip Codes Served by Health Priority Area Programs in FY 05-06............................ 64 Figure 4.3: Children Enrolled by the Children’s Health Initiative ............................................... 69

Figure 5.1: Location of the Special Needs Priority Area Programs in FY 05-06......................... 88 Figure 5.2: Zip Codes Served by Special Needs Priority Area Programs in FY 05-06................ 89 Figure 5.3: Home Locations of Intensively-Served Families in Special Needs Priority Area

Programs in FY 05-06: Fresno County ...................................................................... 90 Figure 5.4: Home Locations of Intensively-Served Families in Special Needs Priority Area

Programs in FY 05-06: Fresno, Clovis, and Sanger................................................... 91

Figure 6.1: Location of Community-Based Initiative Programs in FY 05-06............................ 114 Figure 6.2: Zip Codes Served by Community-Based Initiative Programs in FY 05-06............. 115 Figure 6.3: Home Locations of Intensively-Served Families in Community-Based Initiative

Programs in FY 05-06: Fresno County .................................................................... 116 Figure 6.4: Home Locations of Intensively-Served Families in Community-Based Initiative

Programs in FY 05-06: Fresno, Clovis, and Sanger................................................. 117

vi First 5 Fresno 05-06 Evaluation Report LTG Associates, Inc.

Acronyms Used in this Report

Acronym Name ACC Assessment Center for Children ACS American Community Survey API Academic Performance Index ASE Ages and Stages Social and Emotional Questionnaire ASQ Ages and Stages Questionnaire AyM Abelitas y Mamacitas CAA Certified Application Assistor CBI Community-Based Initiatives CBO Community-Based Organization CBP Community-Based Preschool CCFC California Children and Families Commission CCLS Central California Legal Services CDI Commission Developed Initiatives CDK Child Development Knowledge CHDP Child Health and Disability Prevention CHI Children’s Health Initiative CPD Core Participant Data CSC Children’s Services Coordinator CSN Children’s Services Network CSUF California State University, Fresno CVRC Central Valley Regional Center ECE Early Care and Education EPU Exceptional Parents Unlimited FFF First 5 Fresno FIRM Fresno Interdenominational Refugee Ministries FOS Family Outcomes Survey FUSD Fresno Unified School District GIS Geographic Information Systems HCAP Healthy Communities Access Program HIPAA Health Insurance Portability and Accountability Act IEP Individualized Education Program K-Camps Kindergarten Camps KCUSD Kings Canyon Unified School District LEADS Limitless Early Access and Delivery System NRC Neighborhood Resource Center

vii First 5 Fresno 05-06 Evaluation Report


OCERS Outcomes Collection, Evaluation and Reporting Services (previous database system used by First 5 Fresno)

OERU Outreach, Enrollment, Retention, and Utilization PAERs Project Annual Evaluation Reports PBC Parent Behavior Checklist PITC Program for Infant Toddler Care PO Priority Outcome POC Plan of Care ROR Reach Out and Read SIDS Sudden Infant Death Syndrome SMART Screening, decision-Making, Assessment, Referral, and Treatment StAD State Aggregate Data SR School Readiness SRI School Readiness Initiative TANF Temporary Assistance for Needy Families USD Unified School District

1 First 5 Fresno 05-06 Evaluation Report: Chapter 1


Chapter 1 BACKGROUND AND STRUCTURE OF THE REPORT

1.1 Background on First 5 Fresno’s Current Evaluation Since March of 2004, LTG has been First 5 Fresno’s Commission-level evaluator (see Table 1.1). During that time First 5 Fresno has improved its evaluation in many ways: the Commission adapted the Priority Outcome framework to clarify funding priorities; First 5 Fresno and LTG updated and expanded both the Core Participant Data (CPD) forms and the State Aggregate Data (StAD) forms; several initiative- or program-specific outcome measures were implemented to provide content-appropriate outcome measures for initiatives or projects (e.g., the Ages and Stages Questionnaire, and a modified Nurturing scale from the Parents’ Behavior Checklist); LTG introduced comprehensive qualitative evaluation strategies that involved site visits to providers, and interviews and focus groups with providers and clients; and, First 5 Fresno and LTG created a list of First 5 Fresno core evaluation questions and data sources that guide First 5 Fresno evaluation activities and LTG reporting. LTG’s evaluation of First 5 Fresno activities has moved from a limited set of CPD, Aggregate, and Program Annual Reports to a comprehensive program of data collection that includes system-wide, initiative-wide, and program-specific collection of process and outcome data that provides an evaluation of First 5 Fresno activities with both a high degree of specificity and a broad County-wide perspective. These improvements have placed First 5 Fresno’s evaluation in the forefront of First 5 evaluations across the State (e.g., the addition of qualitative evaluation foreshadowed the new State evaluation framework).

1.2 FY 2005-2006: Early Results from the New Framework In contrast to the previous fiscal year, which was a transitional year with many changes and improvements to the structure of First 5 Fresno’s evaluation, Fiscal Year 2005-2006 (FY 05-06, the year that this Annual Evaluation Report covers) was a year where the baseline results of these adjustments were seen. In FY 05-06 the Persimmony system had already transitioned data from OCERS, providers were administering the new CPD forms and filling out the new StAD forms throughout the entire fiscal year, and programs began collecting Priority Outcome-specific outcome data that would allow a much more topic-specific evaluation of First 5 Fresno’s initiatives. For FY 05-06 these new outcome data provide important baselines for outcomes – baselines that will allow LTG to investigate and demonstrate outcome improvements in future reports.

This is not to say that there were no changes and improvements during the year. In FY 05-06, joint efforts between First 5 Fresno’s Associate Director for Evaluation and Planning and LTG resulted in the production of a more detailed evaluation framework that begins with the Commission’s Priority Outcomes framework and adds a layer of evaluation questions that address specific goals for each Priority Outcome. These questions will guide both the evaluation overall and outcome results reporting in this document.

2 First 5 Fresno 05-06 Evaluation Report: Chapter 1 LTG Associates, Inc.

Table 1.1: Major LTG Accomplishments for First 5 Fresno: Evaluator Data Manager

Year LTG Accomplishments LTG: March 2004 to June 2004 ARC: July 2003 to February 2004

OCERS

FY 04-05 (Evaluation

of FY 03-04)

• Assessed First 5 Fresno’s evaluation activities, local capacity for data collection and data entry, and began providing technical support to projects.

• Established an initial, Fresno-specific evaluation framework that extended beyond State requirements.

• Investigated, cleaned, and analyzed ARC/OCERS data. Produced first LTG Annual Evaluation Report (03-04).

LTG OCERS


of FY 04-05)

• Began streamlining local and state data collection efforts. • Assisted in transition from State Strategic Results to First 5 Fresno

Priority Outcomes framework. • Coordinated transition to Persimmony. • Identified key indicators and Best Practices in support of First 5

Priority Outcome Initiatives. • Produced second Annual Evaluation Report (04-05). LTG Persimmony


of FY 05-06)

• Began building capacity for data collection among providers. • Assisted in transition to new State Evaluation Framework, including

rethinking entire evaluation framework. • Continued to streamline data collection efforts. • Established coordinated Qualitative Studies to support evaluation

framework. • Designed an overall evaluation approach that preceded the new

State focus on qualitative data collection, made it easier to incorporate the new State Framework, and meets State expectations.

1.3 First 5 Fresno Expenditure Overview for FY 05-06 In FY 05-06 First 5 Fresno distributed $12,538,812.00 in expenditures to 90 programs (see Figures 1.1 and 1.2). This represents almost 20% less funding and almost 35% fewer programs from FY 04-05, when First 5 Fresno distributed $15,563,020.00 in funding to 141 programs.

As part of its Strategic Plan for 2001-2002 the Commission divided its program expenditure into two broad categories based on the impetus for the program: Commission Developed Initiatives (CDI) and Community-Based Initiatives (CBI). Commission Developed Initiative programs were funded through solicitations by the Commission for program proposals to respond to particular needs that the Commission wished to address under the Priority Outcomes framework, e.g.,



Figure 1.1: FY 05-06 First 5 Fresno-Funded Program Locations


Figure 1.2: Zip Codes Served by All First 5 Fresno Programs in FY 05-06



Priority Outcome 1, improving the quality of infant-toddler care. This report divides programs funded under the ten Priority Outcomes into the three groups, called Priority Areas, based on the Commission’s grouping of the Priority Outcomes. The three Priority Areas are: (1) Early Care and Education (ECE); (2) Health; and, (3) Children with Behavioral, Developmental, Emotional, Mental Health, and Special Health Needs (Special Needs). The Commission funded 42 Commission Developed Initiative programs in FY 05-06 under the three Priority Areas for $9,279,740.00, or 74% of total program expenditure for the year. Chapters 3 through 5 will present evaluation findings for Commission Developed Initiative programs.

Community-Based Initiatives provide opportunities for individuals, organizations, agencies, and neighborhood and community groups to develop and propose programs, projects, services, and activities to the Commission, and offer groups the flexibility to design their own approaches to serving children and their families. Community-Based Initiatives include General Grants, Capital Grants, and Mini-Grants and Event Sponsorships. Under the umbrella of this funding approach, these grants address various levels of need in the community. The Commission funded 48 Community-Based Initiative programs in FY 05-06 for $3,259,072.00, or 26% of total program expenditures for the year. Chapter 6 presents evaluation findings for the Community-Based Initiative programs. Table 1.2 summarizes First 5 Fresno program expenditures for FY 05-06. Table 1.2: First 5 Fresno Expenditure Summary for FY 05-06

First 5 Fresno FY 05-06 Program Expenditure Total Total Program Expenditures $12,538,812.00 Number of Programs 90

Commission Developed Initiatives (CDI)

Priority Area Expenditures

05-06% of CDI

Total% of FFF

Total Number of Programs

Early Care and Education $6,845,668.00 74% 55% 31Health $864,428.00 9% 7% 6Special Needs $1,569,644.00 17% 13% 5Total $9,279,740.00 100% 74% 42

Community-Based Initiatives (CBI)

Grant Type Expenditures

05-06% of CBI

Total% of FFF

Total Number of Programs

General Grants $2,198,155.00 67% 18% 33Capital Grants $1,006,010.00 31% 8% 3Mini-Grants & Event Sponsorships $54,907.00 2% < 1% 12Total $3,259,072.00 100% 26% 48

1.4 Service Overview In FY 05-06, programs funded by First 5 Fresno served more than 24,761 clients (children, parents, other people connected with child clients, and service providers) through 146,405 service contacts. Service contacts ranged in intensity from participation in workshops, classes, and presentations to one-on-one service provision and counseling. Client counts and service contacts are summarized by client in Table 1.3.


Table 1.3: First 5 Fresno Service Summary for FY 05-06

Client Type Unduplicated

CountService

ContactsIntensively-served Children 0-5 1,924 70,396Children 0-5 9,408 31,639Parents 8,986 26,485Other Family Members 4,599 5,218Service Providers N/A 12,667Total 24,917 146,405

1.5 Evaluation Approach The evaluation of First 5 Fresno is guided by the overarching question: “What impacts or outcomes do First 5 Fresno programs have on children 0-5 and their families in Fresno County?” LTG Associates conducted a broad evaluation of the First 5 Fresno Commission’s activities that does not focus on individual program performance, but rather on the larger shape of the First 5 Fresno Commission’s impact on the children and families that they serve. The primary subjects of this evaluation are the participants directly involved in First 5 Fresno programs: children 0-5 and their families. In order to ascertain any changes in the health, behavior, and systems of care related to children 0-5 and their families in Fresno County, the evaluation was conducted in two ways, using process evaluation and outcome evaluation. Broadly speaking, process evaluations use descriptive data about how programs function, and outcome evaluations use data that indicate change in participants after involvement in First 5 Fresno programs. The sources of data LTG used to conduct these two types of evaluation are enumerated in the next section.

1.6 Sources of Data The primary sources of evaluation data are State Aggregate Data forms (StAD) and Core Participant Data forms (CPD). Both are used as process evaluation data, and CPD follow-up reports provide outcome evaluation data. New this year, outcome data were also measured through other forms (such as the Ages and Stages Questionnaire) that were tied to particular initiatives. Finally, some outcome data came from internal program records, such as One-e-App data for the Children’s Health Initiative. These data were contractually required by First 5 Fresno, and they will be used to answer First 5 Fresno evaluation questions.

In addition to the quantitative data listed above, LTG also conducted site visits with Contract Managers, and the Site Visit Reports are an excellent window into the workings of a program. They offer both process and outcome indicators of program functioning. Finally, LTG also used information from program Project Evaluation Reports, periodic reports written by the contracts and reported to First 5 Fresno, to give a site-based picture of project accomplishments and goals. In addition, other qualitative methods were used such as individual interviews and focus groups.

1.6.1 Interviews and Focus Groups LTG staff conducted 76 one-on-one interviews and 7 focus groups with providers and parents to collect qualitative process and outcome evaluation data. These data were used both as primary and secondary sources, depending on the issue, to answer First 5 Fresno’s evaluation questions. Interviews and focus groups are listed first among sources of data because LTG believes that the



collection and use of qualitative data is a particular strength of First 5 Fresno’s evaluation, one that sets it ahead of the vast majority of County-level First 5 evaluations. When answering outcome evaluation questions where there is qualitative data, LTG is able to provide more than just a simple yes/no answer, but an answer that includes important issues for program, strategy, and design improvements.

Limitations and Improvements The main limitation of the qualitative data is that although LTG staff talked with 69 service providers and 52 clients during the course of the year, not all providers, programs, and clients are represented in the qualitative data. Interviewees and focus group participants were chosen to broadly represent First 5 Fresno’s programs and clients, their ethnicities and languages, in conjunction with guidance from the Associate Director for Evaluation and Planning.

1.6.2 Core Participant Data Core Participant Data (CPD) provided specific data on a subset of First 5 Fresno children who were receiving intensive services through First 5 Fresno programs (see Figures 1.3 and 1.4). Over the past fiscal year, 29 providers collected detailed information on children and families receiving intensive services. Children and families entering the participating programs completed intake forms, service forms, and six-month follow-up forms. Questions and data collected on the forms were in compliance with the California Children and Families Commission guidelines. In general, programs that collected CPD data were school readiness programs, home visitation programs, or other intensive case management or client-based programs.

The CPD data set can be insightful because it provides a concentrated view of the clients being served by First 5 Fresno. Not only does this data set include demographic information, such as living conditions and educational level, but it also provides some information about client and family behavior, e.g., having a medical home or use of childcare. Over time, this client base may provide a view into the changes that are occurring in Fresno County. However, despite the wealth of information that this data set provides, its scope is still limited to a small, but important, section of First 5 Fresno’s client population.

Limitations and Improvements

Currently, CPD forms are being collected in English and Spanish through either the Persimmony system or paper forms. As opposed to FY 04-05, CPD collection progressed without major impediment in FY 05-06. Data collection was confined to the Persimmony system, and most database transition issues have been resolved.

FY 05-06 also marks a stable year for the forms and questions themselves. Data analysis will still be affected by the legacy of form and question changes, but this report has benefited from the ever-growing base of consistent CPD data.

1.6.3 State Aggregate Data The State Aggregate Data set is intended to provide a broad and overarching view of clients and activities that have been supported through First 5 Fresno grants and funding initiatives. During FY 05-06, 73 programs submitted aggregate data to the California Children’s and Families


Figure 1.3: Home Locations of Families Receiving Intensive Services: Fresno County



Figure 1.4: Home Locations of Families Receiving Intensive Services: Fresno, Clovis, and Sanger


Commission through First 5 Fresno. The material was submitted according to the following service categories: Community Strengthening; Direct Services; Provider Capacity Building; Systems Change; and, Infrastructure Investment. Projects categorized as Direct Services, Provider Capacity Building, or Community Strengthening also include participant counts and, if available, counts by ethnicity and language categories.

In addition to client counts, the aggregate forms also collected information on the types of services provided. Seventy percent of the projects reporting by aggregate data forms included direct services, which highlight such modalities as workshops, case management, and other in-person consultations (an increase over FY 04-05, where 58% of programs provided direct services). Other strategies, such as Infrastructure Investment, Provider Capacity Building, and Community Strengthening recorded such events as media campaigns, capital projects, and provider trainings.

The State Aggregate Data set allow a broad look at the clients and services provided in Fresno County because it is one of the few data collection mechanisms that collects information from the majority of programs funded by First 5 Fresno. During FY 05-06, aggregate data were collected through paper forms on a quarterly basis and then entered into the Persimmony system for an electronic state upload at the end of the fiscal year.

Limitations and Improvements The data collected through StAD forms is process data only. No information about clients is collected or reported other than demographic information. More detailed information is collected on a subset of First 5 Fresno clients, those “intensively-served,” through the Core Participant Data module.

For FY 05-06, another evaluation improvement that First 5 Fresno implemented was the reporting of both unduplicated counts of clients receiving services and the total number of service contacts to those clients. This is a vast improvement over the collection of service contacts in FY 04-05. Unduplicated counts demonstrate the size of the population that First 5 Fresno reached, while service contacts demonstrate the amount of effort that programs expended. Both figures are important in gauging the magnitude of First 5 Fresno’s efforts. It will be possible to estimate the total population that First 5 Fresno reached for the first time in FY 05-06.

1.6.4 Project Annual Evaluation Reports Project Annual Evaluation Reports (PAERs), which include Annual Evaluation Reports, Final Evaluation Reports, and Mini-Grant/Sponsorship Evaluation Reports, give providers an opportunity to report on achievements that are not represented in the State Aggregate Data and Core Participant Data. Project Annual Evaluation Reports let the providers tell their stories in narrative fashion, allowing them to highlight their achievements, successes, and challenges. Out of 90 projects, 71 were required to submit project evaluation reports in FY 05-06 (the others were either Mini-Grants or other projects for which First 5 Fresno did not require reports).

Limitations Although the rate of return for PAERs was higher for FY 05-06 than it was for FY 04-05, some of the forms were either incomplete or had cursory answers.



1.7 Structure of the Report Following this chapter is a demographic overview (Chapter 2) that will answer the question “Who is First 5 Fresno serving?” Data from both the aggregate and core participant data sets provide general demographic information such as ethnicity, age, and gender of the clients who received services from First 5 Fresno funded programs. Additionally, this chapter discusses the changes in data collection since the 2004-2005 Annual Evaluation Report.

The next three chapters of this Annual Evaluation Report cover Commission Developed Initiatives. Following the structure of the First 5 Fresno Commission’s structure, we have categorized the ten Priority Outcomes into three general Priority Areas to organize the report: (1) Early Care and Education; (2) Health; and, (3) Special Needs.

The three chapters cover “Priority Area: Early Care and Education” (Chapter 3), “Priority Area: Health” (Chapter 4), and “Priority Area: Special Needs” (Chapter 5). Each of these chapters review the programs categorized under the Priority Outcomes that fit within the chapter’s Priority Area. Chapter 3 examines Priority Outcomes 1 to 3, Chapter 4 reviews Priority Outcomes 4 to 7, and Chapter 5 follows up with Priority Outcomes 8 to 10. In these chapters the goals and rationalization of each Priority Outcome are highlighted. Each chapter includes both qualitative and quantitative process and outcome evaluation analyses. Evaluation findings are assessed through data from qualitative interviews and focus groups, State Aggregate Data, Core Participant Data, project- and initiative-specific data, and Project Annual Evaluation Reports.

Chapter 6 highlights the contracts and grants that were funded under the Community-Based Initiatives. The Community-Based Initiatives are intended to give individuals and agencies in the community the opportunity to be active participants in creating change for children 0-5. The following grant types are presented under this broad umbrella: General Grants; Capital Grants; and, Mini-grants and Sponsorships.

Finally, Chapter 7 provides overarching perspectives on First 5 Fresno’s efforts in FY 05-06, through a discussion of cumulative reflections and implications for the future.



Chapter 2 DEMOGRAPHIC OVERVIEW

2.1 Introduction As in previous years, this Chapter will present demographic data for First 5 Fresno clients served in FY 05-06. LTG provides these data, along with County-wide census data when appropriate and available, in order to give context to the rest of the report.

Data for this chapter are drawn from three sources: First 5 Fresno Core Participant Data (CPD); First 5 Fresno State Aggregate Data (StAD); and, Census data from the US Government. As outlined in

the previous chapter, Core Participant Data provided specific data on a small subset of First 5 Fresno children from 29 programs who were receiving intensive services. Despite the wealth of information that this data set provides, its scope is still limited to a small subpopulation of First 5 Fresno’s client population. The reader will notice that numbers for CPD variable analyses are far smaller than those for StAD variable analyses.

The State Aggregate Data is intended to provide a broad and overarching view of clients and activities that have been supported through First 5 Fresno contracts, grants, and funding initiatives by asking a limited number of questions of all the programs. During FY 05-06, 73 programs submitted State Aggregate Data.

Finally, US Census data for all of Fresno County from the 2005 American Community Survey (ACS) provide an important context within which to view First 5 Fresno’s activities. Census data allow one to understand the makeup of First 5 Fresno’s audience as compared to the makeup of the entire County. It is important to note, however, that First 5 Fresno is not trying to serve a representative sample of Fresno County’s population. Rather, it is targeting needed services and underserved populations.

2.2 Analyses Results

2.2.1 General Demographic Variables Through intensive services First 5 Fresno served 1,924 children, or about 2.1% of the total 0-5 population. Through non-intensive services First 5 Fresno served 9,408 children, or about 10.5% of the 0-5 population. Table 2.1 presents age breakouts for child clients from the FY 05-06 Core Participant Data and State Aggregate Data, along with 2005 American Community Survey Census figures for Fresno County.

Table 2.1 shows that the age breakout of children who received intensive services from First 5 Fresno programs differ from the age composition in Fresno County as a whole. Most of First 5 Fresno’s intensive service clients were children who were between 3 and 5 years of age (roughly 63% of CPD clients), whereas children between 3 and 5 years of age make up only 48.3% of the children in Fresno County. This imbalance is probably due to the emphasis on School Readiness


in intensive-service First 5 Fresno programs. (Note: CPD totals may not add up to 1,924 due to missing data.)

Because the age breakdown for the State Aggregate Data for FY 05-06 is counted by direct service contact rather than by child, it is difficult to assess the age distribution for the children served by the larger set of First 5 Fresno programs (non-intensive service programs). Interestingly however, service contacts suggest that the unduplicated count of children would be evenly split between the younger (0-2) and older (3-5) age groups, similar percentages to the overall 0-5 population in Fresno County. This age-focus difference between intensive and non-intensive service programs is different from FY 04-05, when the two age distributions were more similar. Table 2.1: Age for Children 0-5 Served by First 5 Fresno in FY 05-06

First 5 Fresno Data Intensively-Served

Children State Aggregate Data

(Service Contacts) 2005 ACS Data (Fresno County)

Age of Child Children % Child

Contacts % Children % 0 218 11.4 1 232 12.2 2 263 13.8

16,017 51.4 46,173 51.7

3 388 20.3 4 484 25.4 28,901 32.3

5 323 16.9 15,172 48.6

14,318 16.0 Total 1,908 100.0 31,189 100.0 89,392 100.0

Table 2.2 shows that First 5 Fresno programs provided intensive services to slightly more males than females in FY 05-06, as opposed to FY 04-05 when the proportion was more equal. The proportion of female to male child clients is smaller than the proportion in the 2005 ACS Data for Fresno County. In all probability this represents random variation between years. No State Aggregate Data for gender is presented because the State did not collect aggregate data for gender in FY 05-06. The total number of intensively served children does not include foster children or those who refused consent. Table 2.2: Gender for Children Served by First 5 Fresno in FY 05-06


Children 2005 ACS Data (Fresno County)

Gender Children % Children* %Female 892 46.4 36,359 48.2Male 1,032 53.6 39,049 51.8Total 1,924 100.0 75,408 100.0* Although ACS data is only available for children 0-4, the percentages will be similar for children 0-5

Table 2.3 shows that the majority of children who received intensive services had not moved within the last 12 months. This represents a change from FY 04-05, when the majority of children had moved. While it is possible that the First 5 Fresno intensive service population is becoming more stable, we will wait for next year’s data to confirm the possible trend. This percentage, however, is still lower than the percentage of children who had not moved in Fresno County overall from the 2005 ACS data, suggesting that First 5 Fresno’s client population are more likely to have moved than the general population in Fresno County. No State Aggregate



data was available for this question. Table 2.3: How many times you and your family moved in the last 12 months?

Intensively-Served Children

2005 ACS Data (Fresno Co)

Times Moved Children % Children* %0 610 63.6 45,381 75.31 283 29.52+ 66 6.9 14,848 24.7

Total 959 100.0 60,229 100.0* Although ACS data is only available for children 1-4, the percentages will be similar for children 0-5

Table 2.4 shows that the average household size for children who were intensively-served in FY 05-06 is much larger than the average household size in Fresno County according to the Census in 2005 (there is no State Aggregate Data for this question). Again, this statistic, like the number of moves in the last year, suggests that First 5 Fresno’s service population was not representative of the general population. The average household size hardly changed from the FY 04-05 figure of 5.5 household members. Table 2.4: How many family members in household including you?

First 5 Fresno Data

Statistic Intensively-Served

Children 2005 ACS Data

(Fresno Co)* Average Number of Household Members 5.6** 3.13

* ACS data is only available for ALL households in Fresno County ** N=1064

As demonstrated by Table 2.5, the majority of children who were intensively-served by First 5 Fresno programs in FY 05-06 lived with both biological parents (there were no State Aggregate or Census data for this question). The second-largest category was that of children who lived in single-parent, mother-headed households. Together these two categories accounted for 93.7% of the intensively-served children. These figures have not changed noticeably from those in FY 04-05. Table 2.5: Who is the child currently living with?


Children Who Child is Living With Children %A parent and a step parent 15 1.1A parent and boyfriend/girlfriend 17 1.3Adoptive parent(s) 7 0.5Both biological parents 1,065 81.3Don't know/Declined 3 0.2Father Only 11 0.8Foster Parents 2 0.2Mother only 163 12.4Other 2 0.2Other relative 25 1.9Total 1,497 100.0


Table 2.6 shows that almost 60% of families with children who were intensively-served by First 5 Fresno in FY 05-06 had incomes of less than $20,000 a year. These figures are decreases from those in FY 04-05, when 68% of the families earned less than $20,000 a year. By comparing the First 5 Fresno distribution of incomes to the 2005 ACS Fresno County distribution of incomes, it is clear that First 5 Fresno’s clients are far less affluent than the County population as a whole. As noted above, 59.3% of First 5 Fresno’s intensive service clients earned less than $20,000 a year, compared to the County population, where only 23.9% earned the same amount. Table 2.6: Which category best describes total family income in last year?


Children 2005 ACS Data

(Fresno Co)* Family Income Children % Families %Less than $10K 365 24.6 11,842 10.8$10K – less than $20K 514 34.7 14,400 13.1$20K – less than $30K 226 15.2 16,029 14.6$30K – less than $40K 62 4.2 12,121 11.0$40K – less than $50K 39 2.6 10,594 9.6$50K – less than $75K 36 2.4 17,800 16.2More than $75K 14 0.9 27,086 24.7Don’t know/Declined 227 15.3Total 1,483 100.0 109,872 100.0* ACS data is only available for all families with children 0-18 in Fresno County

Taken together, the data in this section demonstrate that First 5 Fresno’s clients are more likely to live in or near poverty, are more likely to have moved in the past year, and live in larger households than the overall County population. Therefore, they may be more at risk and have more unmet needs than the general population.

2.2.2 Language, Ethnicity and Country of Birth Table 2.7 shows the ethnic/racial distribution of First 5 Fresno clients. Parentheses indicate a group that has been combined into a larger group (e.g., the number of Chinese, 3, was combined with other Asian American/Pacific Islander figures to reach the sum of 400 children from CPD data) for comparability across data sources.

Interestingly, CPD and State Aggregate Data show different trends in their relation to Census data. For CPD data, Asian American/Pacific Islander and Hispanic children are overrepresented in the CPD population, while children with Black/African American, White, and Other ethnicities are underrepresented in the CPD population. It is interesting to note that, although this level of detail was not available for the State Aggregate Data and Census data, the CPD data show that the Asian American/Pacific Islander group covered people from at least six different ethnic populations, of which the Hmong represented the highest served population (17.4%), a substantial increase over FY 04-05. First 5 Fresno served more Hmong in FY 05-06 than previous years. This overrepresentation for Asian American/Pacific Islander children is likely the result of FY 05-06 programs targeted at special populations.

For the State Aggregate Data, only Hispanic children are overrepresented, while children with Mixed, White, and Other ethnicities are underrepresented in comparison to the local ACS data. Clearly First 5 Fresno’s service population is heavily Hispanic/Latino, and is not in proportion to



the overall Fresno County population. As mentioned before, however, First 5 Fresno was not trying to serve a representative sample of the overall County population. First 5 Fresno programs tend to target those who are in need of services, in keeping with the mission of California First 5. Table 2.7: Ethnicity for Children and Parents Served by First 5 Fresno in FY 05-06


Children State Aggregate Data

(Service Contacts) 2005 ACS Data

(Fresno Co)*

Ethnicity Children %Child

Contacts % Children %American Native 2 0.1 43 0.1 948** 1.0Asian Amer/Pacfc Isl 400 21.3 1,978 6.7 6,706 6.9

Chinese (3) (0.2) Hmong (327) (17.4) Khmer/Cambodian (40) (2.1) Laotian (16) (0.9) Other Asian (12) (0.6) Vietnamese (2) (0.1)

Black/African Amer 39 2.1 1,687 5.7 4,329 4.5Hispanic/Latino 1,333 71.0 21,665 73.1 45,727 47.3

Mexican, Mexican-Amer, Chicano (1,302) (69.4)

Other (31) (1.7)

Two or more races 551 1.9 4,085 4.2Other 10 0.5 607 2.0 17,521 18.1Unknown/NA 2 0.1 2,226 7.5 White 91 4.8 2,882 9.7 17,443 18.0Total 1,877 100.0 29,618 100.0 95,811 100.0* Although ACS data is only available for children 0-4, the percentages will be similar for children 0-5 ** Taken from 2000 Census because number was too small for ACS to estimate

As Table 2.8 demonstrates, the dominant languages spoken across clients reported in the Core Participant Data, the State Aggregate Data, and the 2005 ACS data are English and Spanish. Across both the CPD and State Aggregate Data, the percentage of children and parents who speak Spanish is much higher than the percentage of the overall Fresno County population who speak Spanish. Unsurprisingly, the percentage of children and parents served by First 5 Fresno who speak English is much lower than the percentage of people who speak English in the overall Fresno County population.

The third most prevalent language spoken by children and their parents served by First 5 Fresno is Hmong. Hmong is not represented in the 2005 ACS data, but it is the primary language of 15.8% of children intensively-served and 4.4% of children in the other First 5 Fresno programs. These results underscore the importance of considering the language of service delivery when making funding decisions that have an effect on the service climate in Fresno County.


Table 2.8: Language for Children and Parents Served by First 5 Fresno in FY 05-06 First 5 Fresno Data


State Aggregate Data(Service Contacts)

2005 ACS Data (Fresno Co)*

Language Children %Child

Contacts %Children

5-17 %English 452 24.6 8,693 27.5 104,495 53.9Asian Languages 301 16.4 1,417 4.5 15,753 8.1

Hmong (291) (15.8) (1,396) (4.4) Khmer (Cambodian) (6) (0.3) (0) (0.0) Lao (4) (0.2) (0) (0.0) Tagalog (0) (0) (21) (0.1)

Spanish 995 54.1 16,572 52.4 69,042 35.6Russian 21 1.1 0 0.0Ukrainian 12 0.7 0 0.0Other 9 0.5 2,176 6.9 4,591 2.4Unknown 49 2.7 2,781 8.8Total 1,839 100.0 33,056 100.0 193,881 100.0* Census data is only available for children age 5-17 because the Census does not collect language data for children

under 5 years old

The final table in this subsection, Table 2.9, shows place of birth for children who were intensively-served by First 5 Fresno programs in FY 05-06. The overwhelming majority of children served (81.7%, a drop of 5% from FY 04-05) were born in the United States, i.e., not immigrants. Contrast this finding to those in the previous table. Although the vast majority of children who were intensively-served by First 5 Fresno programs in FY 05-06 were born in the United States, only 24.6% primarily spoke English at home (a drop of 7% from FY 04-05). Although the proportion is lower than last year, clearly a sizable proportion of First 5 Fresno CPD clients are non-immigrant children who may live in immigrant families and speak Spanish at home. Because the census does not break down birth country by age, we have left County-level data off the table for this year to avoid confusion. Table 2.9: Country of Birth for Children Served by First 5 Fresno in FY 05-06

First 5 Fresno Data Intensively-Served Children

Country Children %Asia 169 9.1

Cambodia (1) (0.1) Indonesia (14) (0.8) Laos (1) (0.1) Macau (1) (0.1) Thailand (152) (8.2)

Europe 6 0.3Cyprus (1) (0.1) Moldova (2) (0.1) Russia (1) (0.1) Ukraine (2) (0.1)

Latin America/Mexico 86 4.6United States 1,522 81.7Unknown 79 4.2Total 1,862 100.0



2.2.3 Parental Education Table 2.10 shows the highest level of education attained by the mothers of the intensively-served children and comparable statistics for Fresno County from 2005 ACS data. Overall, more than half of the mothers of intensively-served children have less than a high school education (56%), while approximately a quarter of the overall adult female population in Fresno County have less than a high school education. As opposed to the overall population in Fresno County, where almost half have a high school degree or some college, the trend for mothers of children with CPD data is increasingly smaller percentages as the level of education rises, with a bump at Some College. Again, this is probably a characteristic of the underserved population that First 5 Fresno programs target. Table 2.10: What is the highest level of education completed by the child’s mother?

First 5 Fresno Data

2005 Census Data (Fresno Co.)


Mother’s Level of Education Mothers %Women

(Age 18+) %8th grade or less 355 31.0 44,273 14.8Grades 9-11 287 25.1 34,903 11.6High School grad or equivalent 240 21.0 70,180 23.4Trade/Vocational School 35 3.1Associates Degree (AA) 40 3.5 23,901 8.0Some college but no degree 127 11.1 75,268 25.14 years graduate 47 4.1 36,353 12.1Post graduate degree 14 1.2 14,930 5.0Total 1,145 100.0 299,808 100.0

Finally, Table 2.11 shows that the trend for the highest level of education attained by the fathers of the intensively-served children is similar to that of the children’s mothers (Table 2.10). Table 2.11: What is the highest level of education completed by the child’s father?

First 5 Fresno Data

2005 Census Data (Fresno Co.)


Father’s Level of Education Fathers %Men

(Age 18+) %8th grade or less 315 36.4 46,848 16.2Grades 9-11 176 20.3 40,373 13.9High School grad or equivalent 199 23.0 67,138 23.2Trade/Vocational School 19 2.2Associates Degree (AA) 21 2.4 20,307 7.0Some college but no degree 92 10.6 63,709 22.04 years graduate 33 3.8 34,418 11.9Post graduate degree 10 1.2 17,058 5.9Total 865 100.0 289,851 100.0


2.3 Conclusions When the demographic statistics of First 5 Fresno’s clients in FY 05-06 are compared to those of FY 04-05, there are more similarities than differences. Again, the demographic information presented in this chapter demonstrates that the population that First 5 Fresno served in FY 05-06 is not a representative sample from the overall Fresno County population. Demographic analyses suggest that First 5 Fresno’s client population is more at risk than the general population, with lower educational attainment among parents, more moves in a year, more household members, and lower household income than the County as a whole. We point out again, that this should not be considered problematic in the least. First 5 Fresno’s mandate is not to make sure that they provide services to every segment of the Fresno County population, but rather it is to use the Proposition 10 money where it will do the most good for populations with limited access to services and the most unmet needs.

The demographic differences from FY 04-05 indicate that the CPD population and the overall First 5 Fresno population were more similar in FY 05-06 than they were last year. In all probability, however, this reflects nothing more than a shift in program funding from year to year.



Chapter 3 PRIORITY AREA: EARLY CARE AND EDUCATION

3.1 Introduction In many ways Early Care and Education is at the heart of First 5 Fresno’s mission. One of First 5 California’s major goals is to promote school readiness in children 0-5, and the School Readiness Initiative programs fall under this Priority Area. The Quality Infant-Toddler Care, Community-Based Preschools, and Home Visitation initiatives are also aimed at increasing children’s school readiness through improved care environments, parental support, and family support and investment in children’s learning.

In FY 05-06 First 5 Fresno funded 31 programs and disbursed $6,845,668.00 under the Early Care and Education Priority Area. These programs encompass the following Priority Outcomes:

Priority Area: Early Care and Education

Priority Outcome 1: Quality Infant – Toddler Care Improve the capability of ECE service providers to deliver responsive, developmentally appropriate infant-toddler care in accordance with accepted best practices and standards of care.

Priority Outcome 2: Parent/Caregiver Support Increase opportunities for supporting parents/caregivers to nurture their child’s development.

Priority Outcome 3: Utilization of Enrichment Services With an emphasis on innovative, systems level improvements, increase opportunities for all children to receive responsive, developmentally-appropriate enrichment experiences.

3.2 Area Overview Early Care and Education (ECE) is a set of strategies based on First 5 Fresno’s desire to support best practices in this area. During FY 05-06, First 5 Fresno funded several initiatives under Priority Outcomes 1, 2, and 3, all of these addressing specific areas in ECE. According to the 2005-2008 Strategic Plan, under Priority Outcome 1 First 5 Fresno “acknowledges the great need for and importance of maximizing the quality of early care and education” among children 0-3 years. Funding supports services in childcare center and home-based family childcare.

Priority Outcome 2 programs are funded to support yet another set of strategies promoting ECE. They are the result of First 5 Fresno’s recognition of the “essential role parents/caregivers play as their children’s first teacher.” Home Visitation is one of the key interventions under Priority Outcome 2, providing individualized support to families with the goal of improving parent-child interaction and nurturing children’s development and growth.

Last in the ECE strategies are those under Priority Outcome 3. Under this Priority Outcome, First 5 Fresno seeks to expand conventional approaches to creating systems change by increasing


opportunities for children to access quality enrichment experiences, especially in low Academic Performance Index (API)1 areas. In addition to First 5 Fresno’s School Readiness initiative, now covering 13 different schools in Fresno County during the fiscal year, other interventions were added, such as Pre-Kindergarten K-camps (K-camps), community-based home visitation, and additional services to low API areas.

3.2.1 Program Listing and Expenditures Table 3.1 provides program listing and expenditure amounts under the ECE Priority Area. The programs, and their breakout in Table 3.1, will be described in the following sections. Table 3.1: ECE Priority Area Program Listing and Expenditures

Infant/Toddler Quality Care Improvement and Special Needs Inclusion Support Initiative

Contract Number Program Name

Priority Outcome

FY 05-06 FFF Expenditures

2004CP6016 Child Healthcare Linkages Project PO 1 $215,600.00 2005CP6034 Infant/Toddler Quality Care Improvement Special Needs

Inclusion (LEADS) PO 1 $1,282,354.00

Community-Based Home Visitation for Special Populations Initiative Contract Number Program Name

Priority Outcome


2005PA6029 Cambodian/Lao Community-based Early Childhood Education PO 2 $95,162.00 2005PA6027 Home Visitation Program-Centro La Familia PO 2 $121,905.00 2005PA6028 Learning About Parenting PO 2 $123,282.00 2005PA6030 New Connections: Linking Hmong Families to Early Education PO 2 $119,481.00

Community-Based Preschool Initiative Contract Number Program Name

Priority Outcome


2005PA6025 FIRM Family and Community Partners Preschool PO 3 $127,548.00 2005PA6026 Nyob Zoo: Learning to Live Well PO 3 $174,651.00

Family Connections for Unique Populations Home Visitation Initiative Contract Number Program Name

Priority Outcome


2005CP6040 Family Connections SR Low API Huron/Coalinga PO 3 $73,641.00 2005CP6036 Family Connections SR Low API KCUSD PO 3 $188,074.00 2005CP6038 Family Connections SR Low API Malaga/Calwa/Orange Cove PO 3 $285,717.00 2005CP6037 Family Connections SR Low API Parlier/Selma PO 3 $224,153.00 2005CP6035 Family Connections SR Low API SUSD PO 3 $138,415.00 2005CP6041 Family Connections SR Low API Teen Parents PO 3 $90,418.00 2005CP6039 Family Connections SR Low API West Fresno PO 3 $138,250.00

1 API is a school performance measurement system which was first developed as part of California's 1999 Public Schools Accountability Act. Early each year, the state calculates the Base API for each school to establish a baseline for the school's academic performance, and it sets an annual target for growth. Each fall, the state announces the Growth API for each school, which reflects growth in the API from year to year.



Table 3.1: ECE Priority Area Program Listing and Expenditure (continued) School Readiness and K-Camp Initiative

Contract Number Program Name

Priority Outcome


03SR02 Burroughs Elementary School PO 3 $279,376.00 3004SR4008 David L. Greenberg School Readiness Program PO 3 $257,651.00 01SR02 Del Rey Infant and Toddler School Readiness Project PO 3 $283,264.00 2002CP6514 FCEOC Early Head Start PO 3 $0.00 3004SR4010 Firebaugh School Readiness Project PO 3 $238,704.00 3004SR4007 Golden Plains Unified School District - School Readiness Project PO 3 $382,026.00 05SR03 Homan Elementary School Readiness Project PO 3 $251,500.00 3004SR4006 Jane Addams Elementary School Readiness Project PO 3 $681,365.00 2005CP6031 Kindergarten Camp PO 3 $37,022.00 04SR02 Lowell Elementary School Readiness Project PO 3 $262,597.00 3004SR4012 Mayfair Elementary School Readiness Project - FUSD PO 3 $284,178.00 3004SR4009 Raisin City Elementary School Readiness Project PO 3 $161,411.00 3004SR4011 Westside School Readiness Project PO 3 $93,535.00

Other Early Care and Education Projects Contract Number Program Name

Priority Outcome


2005CP6019 California Reach-out and Read PO2 $129,072.00 2005CP6032 Early Learning Center PO3 $100,000.00 2002CP6502 Quality Child Care - Hmong Community Project PO1 $5,316.00

Figure 3.1: ECE Expenditure Distribution for FY 2005-2006

3.2.2 Infant/Toddler Quality Care Improvement Special Needs Inclusion (LEADS)

The Limitless Early Access and Delivery System (LEADS) is the primary program supporting the Infant/Toddler Quality Care Improvement Special Needs Inclusion Support Initiative under Priority Outcome 1. Priority Outcome 1 focuses on improving the capability of ECE service

First 5 Fresno ECE Funding Totaled$6,845,668.00 Dollars

3,212,629, 47%

459,830, 7% 302,199, 4%

1,138,668, 17%

1,497,954, 22%

234,388, 3% School Readiness InitiativeHome Visitation for Special Populations Community Based PreschoolsFamily Connections/ Home Visitation Infant/Toddler Quality CareOther ECE projects


providers to deliver responsive, developmentally-appropriate infant/toddler care in accordance with accepted best practices and standards of care. This initiative also covers interventions from Priority Outcomes 3 and 10.

Children Services Network (CSN) is the lead agency for the initiative, housing its services through the LEADS program. CSN was selected as part of First 5 efforts to fund agencies with demonstrated ability and potential for implementation of services. The agency has been in existence for over 20 years and it has been recognized as “Fresno County’s Child Care Resources and Referral Agency.”2 As part of their services, CSN staff offer parents, guardians, and childcare providers support and education, links to community resources, and resources to assist caregivers advocating for children. One of the main goals of the initiative led by CSN’s LEADS program is to create a networked system of support for caregivers in Fresno County. The primary target group for this program is formal (licensed) and informal (license-exempt) care providers providing infant/toddler care.

The LEADS program was designed to offer the Program for Infant Toddler Care (PITC) trainings to caregivers who provide care for infants and toddlers. PITC is recognized as a best practice approach to teach childcare providers how to help infants and toddlers learn in a developmentally appropriate environment. According to PITC’s mission statement, they believe that: “for care to be good, it must explore ways to help caregivers get ‘in tune’ with each infant they serve and learn from the individual infant what he or she needs, thinks, and feels.”3

PITC helps caregivers design environments that ensure safety, offer infants appropriate developmental challenges, and promote optimum health for children. It also includes a program component that focuses on “the child's developing family and cultural identity by making meaningful connections between childcare and the child's family and culture.”

The goal of PITC is to help caregivers recognize the crucial importance of giving tender, loving care and assisting in the infants' intellectual development through an attentive reading of each child's cues. The PITC's videos, guides, and manuals are designed to help childcare managers and caregivers become sensitive to infants' cues, connect with their family and culture, and develop responsive, relationship-based care.4

In addition to PITC training, the LEADS program provides services to caregivers who care for children with special needs. These special needs services cover key interventions within Priority Outcome 3 and 10. This part of the LEADS program is comprehensive and has as a goal to provide support to caregivers, parents, and children. Caregivers receive specialized childcare training in an effort to increase their capacity to accommodate children with special needs. Along with caregivers, parents receive support to identify inclusive childcare services and options. Both 2 From their web page http://www.cvcsn.org/about_us/mission.html 3 From their web page http://www.pitc.org/pub/pitc_docs/about.html 4 Ibid.



caregivers and parents also receive coaching and information to increase responsive care for children with special needs. The ultimate goal is that children with special needs receive responsive and developmentally appropriate enrichment care experiences.

3.2.3 School Readiness/Home Visitation/Kindergarten Camps These initiatives fall under Priority Outcome 2, Parent-Caregiver Support, and Priority Outcome 3, Utilization of Enrichment Services. First 5 Fresno’s goal was to promote on innovative, systems level improvements, and increased opportunities for all children to receive responsive, developmentally-appropriate enrichment experiences. This is intended to produce an integrated approach to helping children develop school readiness prior to entering Kindergarten. The First 5 California Children and Families Commission (CCFC) website on School Readiness states:

The First 5 CCFC allocated $206.5 million dollars, over a four-year period (2002 to 2006), to implement programs that improve the transition from early care settings to elementary school and increase the schools’ and communities’ capacity to promote the success of young children. School readiness efforts focus on communities with low-performing schools as measured by Academic Performance Index (API) and can be based at schools or in school-linked settings.

At the local level, First 5 Fresno expended a total of $5,113,326.00 for programs that support the school readiness of children. While the School Readiness Initiative is part of a state-wide effort to prepare children to enter school, First 5 Fresno has added initiatives such as Family Connections for Unique Populations Home Visitation (Family Connections), Community-Based Home Visitation for Special Populations (Home Visitation for Special Populations), Community-Based Preschool and supported a number of K-camps in Fresno County to maximize efforts not only to provide early care and education for children, but also to support parents nurturing their children’s development. Figure 3.2: Expenditure Distribution for School Readiness, Home Visitation and K-Camp Programs FY 05-06

School Readiness, Home Visitation and K-CampsFunding in 2005-2006 Totaled $5,113,326.00

$3,212,62963%$459,830

9%

$302,199 6%

$1,138,66822%

School Readiness InitiativeHome Visitation for Special PopulationsCommunity BasedPreschoolsFamily Connections


For instance, Family Connections was developed by First 5 staff using “lessons learned from projects funded by First 5 Fresno and a comprehensive review of research and literature.”5 Programs funded under Family Connections Home Visitation were considered School Readiness Expansion Projects because they were not part of the original School Readiness sites. Family Connections Home Visitation was tailored for elementary schools in Fresno County with Low Academic Performance Index scores (ranking three or lower out of 10), and that did not have School Readiness programs. The success of the implementation of Family Connections was such that by the end of the fiscal year, staff planned to extend it to School Readiness sites already funded by the Commission. The areas in the County covered by the School Readiness Expansion Project were Sanger, Kings Canyon Unified area, Parlier/Selma, Malaga/Calwa/Orange Cove, West Fresno, Coalinga/Huron and Teen Parent Support (countywide). Though Family Connections is not considered to be, or used as, a curriculum, it is used as a guide by home visitors who are employed by School Readiness schools to work in the home with families to teach them how to interact with and prepare their children for school activities.

In addition to the School Readiness Initiative and Family Connections programs, community-based preschools also offered additional opportunities for children to prepare for school. Programs such as FIRM Family and Community Partners’ Preschool and Stone Soup’s Nyob Zoo: Learning to Live Well are examples of the dynamic approaches to produce different opportunities for children to receive school readiness support. These programs aim to develop population-appropriate practices, focusing on the individual child’s interests and needs, and using a wide variety of hands-on activities to stimulate learning. They include activities that have a strong focus on early literacy and on the nurturance of relationships, and they incorporate the four domains of child development: social, emotional, physical and cognitive.

…[the program] has taught me that spending even five minutes with my child talking to me, I can be a better parent. Children need to have more time, we have to balance that. Teachers have taught me how to help my children, how to talk to my kids… (Hmong parent in Fresno)

Similarly, K-camps are a bridge from pre-school activities and home visitation to entry into Kindergarten. For those children who have not experienced pre-school or home visitation, K-camps are a preparatory experience to promote school readiness for Kindergarten. A total of nine K-Camps were funded during the later part of the fiscal year, serving a total of 360 children throughout Fresno County.

3.3 Program Descriptions

3.3.1 Priority Outcome 1: Quality Infant – Toddler Care First 5 Fresno funded three programs in FY 05-06 that fit under the objectives of Priority Outcome 1. Programs in this Priority Outcome aim to increase the capacity of childcare providers and preschools to improve quality care. Of those three, only one program was 5 From First 5 Fresno Family Connections Guidebook



officially categorized as Priority Outcome 1, Limitless Early Access and Delivery System (LEADS). The LEADS program is the lead for the Infant Toddler Quality Care Improvement Special Needs Support initiative. The other two programs are Quality Child Care - Hmong Community Project and the Child Healthcare Linkages Project run by the Fresno County Department of Health. The Quality Child Care – Hmong Community Project received funding in FY 05-06 for services provided in FY 04-05. Therefore, there are no FY 05-06 data on this project.

An important method of increasing the quality of care is ensuring that connections between agencies are strong and information is shared between the agencies within the community. All of the programs under this Priority Outcome participated to some degree in collaborations with community agencies. For instance, The Child Healthcare Linkages Project worked closely with LEADS and the Assessment Center for Children (ACC) to provide resources to children with special needs. In fact, the Child Healthcare Linkages program, as its name suggests, is primarily involved with connecting children to different County services. For all programs, these connections make it easier to direct families to the best resources available. In addition, children and their parents are linked with various community agencies through referrals.

Not only did these programs refer clients and supply information about local resources, but many were used as a local resource for information themselves. These programs provided workshops, trainings, and other educational resources for early childcare professionals. The LEADS program increased the quality of care infants and toddlers received in childcare programs by providing PITC training and technical assistance for childcare providers throughout Fresno County. Three sites chosen as Child Care Demonstration sites by LEADS received funding and intensive PITC training. These programs under Priority Outcome 1 provided training and technical assistance on child development, cross cultural childcare practices, and health and safety information.

While this Priority Outcome focused mainly on the provider level, some services were provided to parents and children in Fresno County directly. Not only did parents receive referrals from the agencies, but the LEADS program, through its LEADS Inclusion Facilitator program, worked with special needs children to promote inclusion in the classroom and in daily activities with family and school. The Child Healthcare Linkages Project directly helps families by teaming up with School Readiness programs to provide information at parent nights. Additionally, the Child Healthcare Linkages project has helped children with developmental needs obtain appropriate assessments and referrals. While moving towards a similar goal, such as better childcare, diverse services were provided to the community.

3.3.2 Priority Outcome 2: Parent/Caregiver Support Five programs fall under Priority Outcome 2: Learning About Parenting; Cambodian/Lao Community-based Early Childhood Education; New Connections: Linking Hmong Families to Early Education; Home Visitation Program-Centro La Familia; and, California Reach-out and Read. Of those five, four have been officially placed under this Priority Outcome and are funded under the Home Visitation for Special Populations Initiative. The fifth program, the California Reach Out and Read Program was placed under this Priority Outcome as a thematic match from the strategic outcome model. The overall goal of this Priority Outcome is to give parents the resources to help stimulate their children’s cognitive and social development.

Home Visitation is a well established method of helping parents develop skills they can use in


parenting. The Home Visitation for Special Populations contracts were issued with this particular focus. The grants target populations in the following areas: parents who do not speak English; parents living in rural areas; parents who are teens or in their early twenties; parents who are single; and, parents of underserved ethnicities, such as Hmong, Cambodian, or Laotian.

Programs that used home visitation as an intervention focused on teaching parents activities that they could do with their child to enhance her or his development. For example, health and safety are key issues addressed by the Abuelitas y Mamacitas Program. Parents in this program have commented on learning about child safety, child development, and child education that they would not have otherwise been knowledgeable about.

All of the programs that were originally funded prior to FY 05-06 and had continuing funding had activities available to the parents and caregivers outside the home. These activities took the form of meetings, workshops, trainings, and other educational classes. One program provided monthly parent education sessions in which parents were also referred to services that were specific to the families participating in the program. Programs also provided a significant number of parenting classes where parenting skills, child development, and community services were among the many topics.

In the home, activities specifically available to children included reading books and playing with toys, both with the home visitor and with other children. The Cambodian/Lao Community-based Early Childhood Education home visitation program invited other children, like neighbors and siblings, to participate in the home visiting session. This inclusion of other children improved children’s ability to share toys and read together after the home visitor had left. This inclusion of other children is an example of the ripple effect of First 5 programs.

Programs also participated in a number of other diverse activities. The Home Visitation Program-Centro La Familia staff acquired donations to supply membership and swimsuits to mothers and children so that they could go swimming, making physical activity and shared playtime with mothers and children available outside the home but still in the community. Additionally, all of the programs collaborated with each other and provided referrals for children and parents with specific medical or social needs.

3.3.3 Priority Outcome 3: Utilization of Enrichment Services Priority Outcome 3 focuses on the importance of preschool for young children. First 5 Fresno funded 23 programs in FY 05-06 under this Priority Outcome. Of these programs, 13 were funded under the School Readiness Initiative (SRI), 2 were funded under the Community-Based

Preschool Initiative (CBP), 7 were funded under the Family Connections for Unique Populations Home Visitation Initiative, and 1 program was funded separately (see Table 3.1).

All of the SRI programs are under Priority Outcome 3. These programs are composed of multiple components helping parents and children with many different types of services. First 5 Fresno follows the five state-outlined elements, which

are as follows: early care and education (ECE); parenting and family supports; health and social services; school capacity; and, infrastructure and administration. All of these five elements were initiated in 11 elementary schools, chosen because of their locations and low API scores.



Together these elements create an all-inclusive approach that helps children in these schools be as prepared as possible for school. A number of direct services are provided to children and families, including: enriched childcare or preschool; home visitation; parenting classes; developmental assessments; health assessments (including oral health); transportation; and, counseling.

On a basic level, this Priority Outcome encourages the participation of children in preschool or enriched childcare. Most of the programs offered either enriched childcare or preschool, and occasionally both. In addition, a few programs, particularly SRI programs, offered families Kindergarten Camps. Kindergarten Camps (K-Camps) are held during the summer for three consecutive weeks. The K-Camps program is intended to provide children who have had little or no formal preschool experience the opportunity to overcome some of the initial barriers they may experience as they enter Kindergarten and transition to a structured school program. The programs under this Priority Outcome provided an opportunity for parents who had both economic and other barriers to childcare to enroll their children in a pre-Kindergarten program, such as K-Camps. Some programs, like the Del Rey School Readiness Program, offered enriched childcare, infant care, and K-Camps. The comprehensive array of opportunities for both children and parents gave providers the chance to assess speech and developmental stages of children. An unintended benefit of this comprehensive approach was that parents were taught better parenting skills that enhanced employment skills, thereby increasing their chances to improve their family’s economic status. Children, on the other hand, are directly affected through these programs; they are taught the basic social and academic skills that prepare them to start Kindergarten.

A number of programs, including SRI programs, approach preparing children for school through home visitation. Providers can interact with parents or caregivers in the home setting and thus allow a more personally focused method of helping parents learn ways to help their child be ready for Kindergarten. The home visitation curriculum varies across programs, with the majority utilizing the Family Connections and a few using others such as HIPPY (Home Instruction for Parents of Preschool Youngsters). The HIPPY curriculum, implemented by both Mayfair and Lowell Elementary, helps the parent and child bond through developmentally enriching activities. In addition to home instruction, the home visitation teacher develops better understanding of the family, as well as a trusting relationship, and thereby is more aware of specific needs the family might have. For example, the Westside School Readiness Project staff described a situation where the home visitation teacher helped refer a mother to counseling for domestic violence. Through the home visits, the home visitation teacher and the mother were able to establish a close and trusting relationship, where the mother felt comfortable disclosing the domestic abuse. In general, the home visitation teacher also helped parents learn about resources in the community available to them.

Parents also were provided support through a number of other means, such as workshops, classes, support groups, and trainings. In these events, parents learned about a number of diverse topics. In the Burroughs Elementary School Readiness Project’s Annual Evaluation Report to First 5 Fresno they discussed the workshops they offered:

The workshops included prenatal care, parenting techniques for age 0–teens, reading and math workshops, family science night, family reading night, etc. We had 20 parents who graduated from the workshops and received certificates in recognition of their participation in the workshops.


These programs provided parents an opportunity to meet other parents while learning about important topics for their child’s development.

One key finding in Priority Outcome 3 is the extent to which the programs were able to demonstrate how family economics, health, and social relationships are inter-connected and have an impact on children and their preparedness for school and life. For example, the Mommies Club, through the Addams School Readiness Program, serves an area that is economically disadvantaged and where families need comprehensive support and services to address their needs. The Mommies Club provided a safe space for mothers to talk about their experiences as parents. One mother in particular found that after building relationships in a secure environment with other mothers, she started talking about the real issues that affect her ability to be a good mother. She faced depression due to marital conflict. By having support from other mothers and the program counselor, she was able to take the necessary and yet difficult steps to remedy this situation, and in doing so, also attended additional courses and learned improved ways to support her child.

Support was also provided to parents in basic practical ways, such as providing bus tokens or transportation to medical appointments. Many participating families had very limited incomes, and the programs directly addressed these needs by providing food and clothing, when necessary or on holidays, and/or helping families connect to services that would provide them with these basic needs.

A number of the programs under this Priority Outcome also provided medical and dental health screenings. Some programs, such as those based in schools, had nurses on staff. Others collaborated with other programs that would provide these services. Programs also helped parents and children determine eligibility and apply for medical insurance such as Medi-Cal, Healthy Families or Healthy Kids. In addition to traditional medical screenings, providers also used tests such as the ASQ to determine if a child had any developmental delays. Programs coordinated with the Assessment Center for Children to ensure that those children that had special needs were provided services and resources to meet those needs. Preparing children for school does not only mean that children are academically prepared for school, but also that their basic needs for clothing, food, and medical care are met. One program had a nurse available to provide health screenings through all the programs it provided including: school readiness; enriched childcare; and, Kindergarten camp. The nurse became an integral part of the screening and assessment process, as well as a member of the health evaluation team for children in need.

3.4 Program Locations and Service Areas

3.4.1 Program Location Map Figure 3.3 shows the location of all Early Childhood Education programs throughout Fresno County funded in this Priority Area for FY 05-06.

3.4.2 Program Service Area Map Figure 3.4 shows program service areas, defined by program report of Zip Codes that they serve, for all Early Childhood Education programs funded in this Priority Area for FY 05-06.



Figure 3.3: Location of the ECE Priority Area Programs in FY 05-06


Figure 3.4: Zip Codes Served by ECE Priority Area Programs in FY 05-06



Figure 3.5: Home Locations of Intensively-Served Families in ECE Priority Area Programs in FY 05-06: Fresno County


Figure 3.6: Home Locations of Intensively-Served Families in ECE Priority Area Programs in FY 05-06: Fresno, Clovis, and Sanger



3.4.3 CPD Family Location Map Figure 3.5 shows the home locations for families who were receiving intensive early childhood education services in FY 05-06 throughout Fresno County. There were 2,365 families who received early childhood education services in Fresno County. Of these 2,365 families, 1,691 families are represented on the map, and 674 families are not represented because of missing or incorrect addresses. There are several potential reasons for missing address data For example, clients may have chosen not to provide address information, and/or providers did not collect address information. In other cases, P.O. Box addresses were provided, and because those addresses do not include an actual street address, they cannot be mapped geographically. Finally, a few addresses did not match the zip code that they were listed with, and these discrepancies could not be resolved.

Figure 3.6 shows intensively-served families’ home locations for those in the Cities of Fresno, Clovis, and Sanger.

3.5 Process Evaluation This section presents process evaluation data for programs in the ECE Priority Area, collected primarily through State Aggregate Data (StAD) forms (collecting separate data on Community Strengthening Efforts, Direct Services, Infrastructure, Provider Capacity Building, and Systems Change Support) and Core Participant Data (CPD) service forms. Because these data are reported to the State First 5 Commission separately, they will be presented with little interpretation.

There were a total of 31 programs dealing with Early Care and Education in this Priority Area. As Table 3.2 shows, most were concerned with providing Direct Services. In interpreting the following data, it is important to remember that each program may have submitted more than one StAD form, depending on their program activities. For example, the same program could have submitted one Direct Services form AND one Infrastructure form. Table 3.2: ECE Priority Area, State Aggregate Data Form Summary

State Aggregate Data Form

Programs Turning in

Form* Community Strengthening Efforts 4 Direct Services 25 Infrastructure 1 Provider Capacity Building 6 Systems Change Support 12 * A program can turn in multiple forms.

The next two tables summarize statistics from the 4 programs submitting Community Strengthening StAD forms. Table 3.3 shows that the most frequently used modality was Community Events. In addition, although more people were reported served through Media Campaigns, the audience estimates for Media Campaigns are more difficult to estimate than audience estimates for Community Events.


Table 3.3: Community Strengthening Modality

Modality Number of Programs

Estimated Size of

Audience Organizing community associations/networks 1 500 Community events, celebrations, fairs 3 1,062 Media campaigns 1 60,000

Table 3.4 shows that the most common topics covered by programs (programs could report more than one) were School Readiness and Community Resource Awareness. Table 3.4: Community Strengthening Topics

Topic Number of Programs

Tobacco cessation 2 School readiness 4 Children with disabilities and special needs 2 Community resource awareness 4 Safety education and violence prevention 3 Prenatal care 1 Nutrition 2 Preventive health care for children 2 Positive parenting practices 3 Peer support networks 1

The next five tables summarize statistics from the 25 programs submitting Direct Services StAD forms. For the first time in FY 05-06, programs were required to report unduplicated counts of clients on Direct Services forms. Direct Service and Core Participant data in Table 3.5 shows that First 5 Fresno ECE programs providing Direct Services to clients in FY 05-06 served almost 13,000 clients and provided almost 110,000 service contacts to those clients, almost 90,000 of which were to children aged 0-5 years old, both substantial increases over FY 04-05. Table 3.5: Direct Services Unduplicated Counts and Service Contacts

Type of Client Served Unduplicated Client Count

Service Contacts

Intensively-served Children 1,461 67,072Directly-served Children 4,709 22,935Indirect service to Children 3,499Parents/Guardians 4,360 13,207Other 2,431 2,776Total 12,961 109,489

In Table 3.6, service contacts are categorized by several client demographic factors. The majority of service contacts for children were to Hispanic/Latino children (78.5%, an increase of 8.5% over FY 04-05), children who primarily spoke Spanish (64%, about the same as FY 04-05), and children who were between the ages of 0 and 3 years old (54.8%, a change from FY 04-05, when more children between 3 and 5 received service contacts). Children who have special needs, a small percentage of the population, received 251 direct service contacts, and 74 indirect service contacts through parents and others.



Table 3.6: Direct Services Service Contacts by Client Demographic Children 0-5 Parents/Guardians

Client Demographic Service

Contacts %Service

Contacts %# of Service Contacts by ETHNICITY

American Native 39 0.2 14 0.1Asian 1,685 7.3 1,112 8.4Black 1,477 6.4 603 4.6Latino 17,996 78.5 10,353 78.4Multiracial 204 0.9 53 0.4Other 167 0.7 53 0.4Pacific Islander 15 0.1 11 0.1Unknown 116 0.5 60 0.5White 1,236 5.4 948 7.2Total 22,935 100.0 13,207 100.0

# of Service Contacts by LANGUAGE English 6,085 26.5 4,186 31.7Hmong 1,247 5.4 938 7.1Other 809 3.5 182 1.4Spanish 14,671 64.0 7,792 59.0Tagalog 21 0.1 6 0.0Unknown 102 0.4 103 0.8Total 22,935 100.0 13,207 100.0

# of Service Contacts by SPECIAL NEEDS STATUS OF CHILD Served Directly Special Needs 251 1.1Non-Special Needs 22,684 98.9Total 22,935 100.0Served Indirectly through Parent/Guardian Special Needs 74 1.4Non-Special Needs 5,244 98.6Total 5,318 100.0

# of Service Contacts by AGE OF CHILD Served Directly Children 0-3 12,575 54.8Children 3-5 9,942 43.3Age Unknown 418 1.8Total 22,935 100.0Served Indirectly through Parent/Guardian Children 0-3 3,147 59.2Children 3-5 1,982 37.3Age Unknown 189 3.6Total 5,318 100.0

Table 3.7 shows that the most frequently used modality for Direct Services was Class/Workshop, which 22 of the 31 programs used to provide more than 14,000 of the 36,000 total contacts.


Table 3.7: Direct Services Service Contacts by Modality Children 0-5 Parents/Guardians

Modality

Programs Using

Modality Service

Contacts %Service

Contacts % Case management 12 386 1.7 498 3.8 Class/workshop 22 9,536 41.6 4,939 37.4 Home visit 8 6,980 30.4 4,702 35.6 In-person consult/service 13 5,126 22.4 1,758 13.3 Mobile service 6 222 1.0 781 5.9 Other 9 536 2.3 253 1.9 Phone consultation 3 7 0.0 42 0.3 Public/community event 2 125 0.5 63 0.5 Support group session 4 17 0.1 171 1.3 Total 22,935 100.0 13,207 100.0

In addition to programs providing Direct Services, 22 programs in the Early Care and Education Priority Area provided intensive service to clients and their families. These intensive-service programs all administered Core Participant Data forms to parents at intake, and every 6 months thereafter. These programs served 1,461 children from 0-5 with 67,072 service contacts over 31,331 hours of service.

Only one program in the Early Care and Education Priority Area submitted an Infrastructure Investment form. Table 3.8 shows the program’s report of Infrastructure Investment fund use. Table 3.8: Infrastructure Investment Activity

Activity Programs Engaging

in Activity Facilities: Building new facilities 1 Purchasing: Computers and office equipment 1 Purchasing: Play equipment 1 Purchasing: Furniture 1 Purchasing: Other equipment or materials 1 Other infrastructure investment 1

The next two tables summarize statistics from the 6 programs submitting Provider Capacity Building StAD forms. Table 3.9 shows that ECE programs providing Capacity Building services to providers in FY 05-06 provided more than 9,000 service contacts to providers, mostly center-based ECE providers. Again, it is important to note that the figures in the following tables represent service contacts and not unduplicated counts of participants. Table 3.9: Provider Capacity Building Service Contacts by Type of Client Served

Type of Client Served Service

Contacts %Family-based ECE providers 1,941 20.4Center-based ECE providers 4,778 50.3Kindergarten teachers 3 0.0Health care 45 0.5Family support 479 5.0Other 2,170 22.8Unknown 84 0.9Total 9,500 100.0



Table 3.10 shows that the most common Provider Capacity Building training topic reported (programs could report more than one) was Other Provider Capacity Building Activities. Table 3.10: Provider Capacity Building Training Topics

Training Topic

Programs Covering

Topic Serving disabilities and special needs 3 Cultural diversity training 3 Licensing/accreditation 3 Practices or information to support school readiness 4 Other 5

Twelve programs in the ECE Priority Area submitted Systems Change Support forms for FY 05-06. Table 3.11 shows that the most common Systems Change Support activity (programs could report more than one) was Organizing Meetings to Share Information, Coordinate, or Make Decisions, which 9 of the 16 programs used. Table 3.11: Systems Change Support Activity

Activity

Programs Engaging in Activity

Training programs to conduct evaluations and use data 2 Conducting community asset mapping/needs assessment 2 Conducting research or evaluation 1 Supporting involvement of residents on boards and implementation 1 Community planning efforts involving residents 2 Other civic engagement 1 Meeting with/educating policymakers 3 Preparing documents to support policy changes 1 Writing proposals to request additional funds 2 Preparing/implementing sustainability plans 1 Other raising or leveraging of funds 1 Developing or monitoring service quality standards 2 Developing new training materials for service providers 2 Other service quality improvement 4 Developing programs/materials for diverse populations 8 Providing outreach to underrepresented providers 3 Other working competently with diverse populations 5 Establishing or maintaining registries and databases 3 Organizing meetings to share information/coordinate/decisions 9 Organizing meetings among providers to coordinate cases 5 Developing systems to blend funding streams 2 Other interagency collaboration 8 Universal health care or augmentation of health insurance 1 Universal preschool or expansion of ECE slots 1 Other efforts to increase accessibility 4 Other systems change activities 2


3.6 Outcome Evaluation

3.6.1 Priority Outcome 1: Quality Infant–Toddler Care The goal of Priority Outcome 1 (PO1) is to “[i]mprove the capability of ECE service providers to deliver responsive, developmentally appropriate infant-toddler care in accordance with accepted best practices and standards of care.” First 5 Fresno has addressed this goal by funding the Limitless Early Access and Delivery System (LEADS) to implement provider training and support programs, including training within the Program for Infant Toddler Care (PITC) system.

First 5 Fresno and LTG have determined that the three key evaluation questions for this PO are:

• Have providers/agencies improved their quality of childcare? • Have First 5 Fresno-funded efforts (technical assistance and support) contributed

to improvements in providers' ability to provide quality care for children? • Have providers/agencies changed the way they work to maximize efficiency and

access to services through child/care providers for 1) all children and families; 2) children with health needs; 3) children with special needs?

Have providers/agencies improved their quality of childcare? YES, with the greatest improvements coming from advanced training The primary data used to answer this question is a report on the results of PITC training that First 5 Fresno commissioned from WestEd. WestEd conducted observations of teacher and program quality in center- and family-based daycares before and after teachers underwent PITC training, and then compared the pre- and post-training results to investigate whether teachers and centers had improved in quality of childcare.

• There are three rounds of training (Plan I through Plan III) in the PITC system, and observations were carried out before any training, after Plan I training, after Plan II training, and after Plan III training.

• 53 teachers (from 40 programs) were observed before and after Plan I training, 15 teachers (from 11 programs) were observed after Plan II training, and 4 teachers (from 3 programs) were observed after Plan III training. Therefore, the majority of the data in the report apply to pre- and post- Plan I training observations.

• Data analyses on pre- and post-Plan I data showed some positive results and some negative results: significant improvements in teacher warmth and non-significant improvements in interactions; but, also a significant increase in teacher distancing and non-significant increase in teacher criticalness (the report notes, however, that increases in teacher distance are common after Plan I training as he or she is learning to observe and not interrupt the children in her or his care).

• Data analyses on those few teachers who had post-Plan II or III observations showed more consistently positive results: continued improvements in interactions and warmth, as well as decreases in distance and criticalness.



• Programs showed no improvements in quality of care after Plan I. Programs did show improved quality of care after Plans II and III in the areas of family partnerships, cultural responsiveness, inclusion of children with special needs, and relationship-based care.

• They note that these results indicate that incorporation of PITC essential policies into program practices takes time. They also note that the programs whose providers participated in Plan II and III training tended to have policies and practices in place to support relationship-based care giving.

• They also found that dissatisfaction with pay, benefits, lack of respect, few opportunities to develop professional skills, and little control over decision-making were related to teacher turnover.

Overall, the WestEd report demonstrated improvements in quality of care after First 5 Fresno-funded PITC training at both the teacher and program level, but results indicated that improvements are far more likely after participation in Plan II and III.

Have First 5 Fresno-funded efforts (technical assistance and support) contributed to improvements in providers' ability to provide quality care for children? YES, but providers wish for timelier training enrollment and more slots Qualitative evidence for the answers to these two questions came from eight provider interviews and two focus groups (see Table 3.12). The eight individual provider interviews were with the major LEADS administrative and program staff. The two focus groups included: one PITC trainee focus group with seven participants; and, one non-PITC trainee focus group with three participants.6 Table 3.12: Qualitative Data Collection Activities for PO 1

Infant Toddler Care Initiative Qualitative Interviews & Focus Groups Summary

Type of Event and Participants Number of Events

Number of Participants

LEADS Provider Interviews 8 8 PITC Provider Focus Group 1 7 Non-PITC Provider Focus Group 1 3 Total 18

Seven out of seven PITC trainees interviewed agreed their training improved the care they provided. Everyone was quite enthusiastic about the training and the improvements in their professionalism and quality of care. Notable consensus was found in the PITC focus group, as follows.

• All providers were different. Some were owners, administrators, or employees of

6 Originally 8 of non-PITC trainees had accepted and confirmed the invitation for this focus group but only 3 appeared. In spite of this not being an optimal number, we proceeded with the focus group as this particular group was very difficult to convene and there had been several (at least 4) cancellations prior to this meeting when no one kept their appointments with the focus group convener.


large daycare centers, while others had a daycare center at home. • The types of daycare center and the relationship of the provider to the care center

seem to affect the degree to which providers implemented practices learned during trainings. Access for children with special needs also was determined by the type of daycare center.

• Overall, most providers indicated that during the training they learned about the importance of greater parent involvement, and how to talk with parents better, particularly if their child exhibited a potential developmental delay. Providers also reported learning and implementing best care practices when caring for infants and toddlers, and they offered examples of how techniques learned were useful.

• Providers found support by the LEADS team to be very useful even though some did not need to access services. Providers reported that it was good to know about LEADS both as a direct resource and in terms of the work they do that can aid providers.

• All providers saw a benefit in the training, and they reported learning and enjoying the teachers and the materials they received.

• The only thing that providers indicated could be improved was the length of time it takes to enroll in the first training. Two providers reported having to wait about a year before they could attend.

Have providers/agencies changed the way they work to maximize efficiency and access to services through childcare providers for 1) all children and families; 2) children with health needs; 3) children with special needs? YES, with the exception of speech therapy Primary evidence for the answer to this question comes from qualitative data from a focus group with non-PITC providers as defined by First 5 staff. Additional data were collected by LTG, however, in individual interviews with LEADS staff. Three non-PITC providers participated in the focus group. They worked with different daycare centers in Fresno City. The daycare centers were described as subsidized childcare, with multiple sites throughout Fresno and with waiting lists. One of the centers has at least 60 employees and, according to the participant, all of them have received support from LEADS. These providers reported receiving a number of services through the LEADS team, which included trainings on such topics as discipline and literacy. They also received site visits to help staff role model on how to work with children with identified special needs, how to work with the parents, connect the parents to services, and provide additional resources to early care and education providers at the centers. Two of the non-PITC participants indicated that their corresponding centers see about 100 children combined every day of the week.

The following notable points were made by providers.

• They were very satisfied with services and support received from the LEADS team.

• The LEADS team was able to help these centers through hands on experience in how to care for a child with special needs, identify needs through screening, and provide counseling support to parents before referrals are made.



• The LEADS team works with the centers to coordinate services for parents and child if a special need is identified.

• Speech therapy is a difficult service to obtain in a timely manner despite referrals. They said some children have to repeat Kindergarten as a result of the lack of coordinated care.

We’ve been using some of the techniques that they’ve been providing to us. And like I say with the parents, with the kids, the teachers, they’re very grateful to have that kind of support. … We have special needs children, and they came in and really worked with us trying to get ways of handling our children. And they stayed for months helping with that, and that was really helpful. [Childcare Provider in Fresno County]

According to LEADS staff, they have developed a model program for California with their Special Needs Inclusion Team (SNIT).

Interviewer: How comprehensive do you think LEADS as been in reaching all the early care and education providers in Fresno County about special needs since you started?

SNIT member: I think we have done a pretty good job of reaching out to everyone, despite the fact that we are a model program in California and we are new and still developing…I think we are the first type of program that is actually focused on children ages 0-5 that have special needs and we go out and advocate for those children that are in early childcare.

Interviewer: So this is one of a kind in California?

SNIT member: Yes.

In addition to going out to both center-based and home-based providers to provide workshops; technical assistance; mini-grants for special needs improvements; and, trainings, information, referrals, and advocacy regarding children with special needs, LEADS SNIT staff also have case meetings to keep everyone in the organization apprised of their special needs cases:

In our staff meetings, we…usually sit down and go over our cases and usually the child care/health linkages nurse will join us on those Tuesdays. We meet every other Tuesday…and we will discuss our cases, the progress we are making, and we stay in contact with each other so everybody is on the same page with the progress [of each child. [SNIT member]

Another source of data for this question is the Child Health Care Linkages PAER. This project trained providers to improve the way they work to increase access to children and families in need of services through referral and health care coordination. Sixty-one children and their families have been served this fiscal year and have been successfully linked to services for: medical needs; mental health needs; early intervention; special equipment; access to medical insurance and a medical home; housing; Temporary Assistance for Needy Families (TANF); food stamps; family counseling; grief support; and, other local resources.


3.6.2 Priority Outcome 2: Parent/Caregiver Support; and, Priority Outcome 3: Utilization of Enrichment Services

Because First 5 Fresno has addressed these Priority Outcomes through the funding of multi-service programs that generally address both POs at the same time, we will address outcomes for both POs in the same sub-section.

The goal of Priority Outcome 2 is to “[i]ncrease opportunities for supporting parents/caregivers to nurture their child’s development.” The goal of Priority Outcome 3 is “[w]ith an emphasis on innovative, systems level improvements, increase opportunities for all children to receive responsive, developmentally-appropriate enrichment experiences.” First 5 Fresno addressed both these goals by funding three main initiatives: Home Visitation for Special Populations programs; School Readiness Initiative programs; and, Family Connections Home Visitation programs.

First 5 Fresno and LTG have determined that the key evaluation questions for these POs are:

• Has First 5 improved access to ECE services? Has understanding, access, and utilization of preschool and ECE services improved for parents/caregivers from communities that may not be as familiar with these services because of cultural and/or linguistic characteristics?

• Have First 5-participating parents/caregivers improved their knowledge and practices of child development and improved the quality of parent-child interactions?

• Did services have impacts on children’s developmental progress and well being? • Has First 5 influenced providers serving low API areas to adopt and implement

home visitation best practices? • Has First 5 improved access to school readiness and transition services by

creating a network of coordinated ECE providers in targeted low API areas? Have funded providers improved system coordination, communication, and efficiency?

• Are K-camp children better prepared to enter Kindergarten as a result of the service? Do they benefit as a result of K-Camp participation?

Has First 5 improved access to ECE services? Has understanding, access, and utilization of preschool and ECE services improved for parents/caregivers from communities that may not be as familiar with these services because of cultural and/or linguistic characteristics? YES The answer to this question comes from multiple sources: process data; Program Annual Evaluation Reports; and, qualitative interviews and focus groups.

From process data it is clear that First 5 Fresno has created opportunities for greater access to ECE services by funding 25 Direct Service programs that served 4,709 children with 22,935 service contacts, and 22 intensive-service programs that served 1,461 children with 67,072 service contacts in FY 05-06.

Evidence for improvements in populations that may not be as familiar with ECE services comes from both PAERs and qualitative work. An example of improvements in parental understanding comes from the Slavic Kids in Focus PAER. The Slavic Kids in Focus/FIRM program reports



success with changing parents’ long-term attitudes concerning their interaction with their children. Traditionally, parents believed that children should interact and play with peers rather than with adults. After participating in the program, parents began to see that having adult/child interaction is important for the development of their children and has benefited the parents in understanding the developmental stages of their children more intimately than before.

Evidence for this answer also come from qualitative focus groups and interviews (see summary of qualitative work for POs 2 and 3 in Table 3.15 below) with both School Readiness Family Connections Home Visitations programs and CBO home visitation programs.

School Readiness Family Connections Home Visitations programs were sampled in consultation with First 5 staff. Ten programs were interviewed both individually and in a provider focus group. The ten schools were: Addams; Del Rey; Firebaugh; Golden Plains; Greenberg; Homan; Malaga; Mayfair; Sanger Unified School District; and, Wilson.

In the provider focus group, nine staff members attended, representing eight schools. In addition, eight staff members were interviewed individually on site at Homan and Del Rey. Eight parents from four of the sampled School Readiness/Family Connections Home Visitations sites were individually interviewed: five Latinos and three Hmong. They were from Del Rey, Greenberg, Homan, and Wilson. In addition, a focus group was conducted with five parents at Firebaugh.

Three CBO Home Visitation Programs were sampled: Stone Soup; Khmer Society; and, Fresno Interdenominational Refugee Ministries (FIRM). Seven staff from both Stone Soup and Khmer Society participated in a focus group. Staff members from FIRM were unavailable for interviews during the study period. Table 3.13: Qualitative Data Collection Activities for PO 2 and PO 3

Community-Based Organizations Preschools Qualitative Interviews & Focus Groups



Client Interviews 5 5 Client Focus Group 1 12 Provider Focus Group 1 7 Total 24 School Readiness/Family Connections/Home Visitation

Qualitative Interviews & Focus Groups



Provider Focus Group 1 9 Provider Interviews 8 8 Client Focus Group 1 5 Client Interviews 8 8 Total 30

K-Camps Qualitative Interviews & Focus Groups



Administrator/Coordinator Interviews 2 2 Staff Interviews 8 8 Client Interviews 12 12 Total 22


There was also a focus group with 12 parents from Stone Soup. It was a mixed group of Hmong, Latino, and other Southeast Asian parents. There were translators to assist with the discussion. Finally, five parents from FIRM were individually interviewed: three Hmong; one Khmer; and, one Ukrainian parent.

Parents report that they have learned how to do things differently with their children to prepare them for school. Here we hear from a rural Latino parent:

It is like when we go to a new job and we don’t know anything….With this program, children go better prepared to preschool. They are already socialized with other children; they will also know a little of what they are going to learn, like figures, their names, drawing, about following rules...For example, for my child it has been difficult to learn her colors. I think that many times she gets confused and sometimes we emphasize too much, this is blue, blue, and all she does is repeat it, but does not learn it. Now, I change my method [because of the Home Visitor]. Now, thanks to the classes I tell her, “Oh, look at that pretty blue dress. We’re going to dress you up with a pretty blue dress with blue socks because you are going to look so pretty.” When I do it that way, I am introducing new words for her instead of just having her repeat colors, “This is blue, this is red.”…So I know I need to answer her in the way in which she can learn best. [SR Client]

And for this other urban mother, her child’s schooling is like a second education for her in English, as well as teaching her to be a teacher:

Interviewer: Could you share what you’ve learned, how has this program helped you?

Parent: Well, also that I am learning my colors [laughter], I never learned the colors in English so now I know them too. I also count, and now I know how to play with my child …

And it has also helped me a lot because I was also very shy and now I am also not so embarrassed to ask questions. I come to the school and ask questions [of the teacher]… Now I know how to help my child...I am also learning…It is like I am also in preschool. [SR Client]

Parents noticed that their children who go through the Home Visitation program learn things more rapidly than their previous children who did not have such learning opportunities:

Wherever [my child in the program] sees ABC, the numbers, he knows them. If I compare him with all my older children, [who did not] go to school until the age of 5, and were taught ABC [then]. It took them at least 2 years to know as much as this one now knows (at the age of 4). [SR Client]

Have First 5-participating parents/caregivers improved their knowledge and practices of child development and improved the quality of parent-child interactions? YES, YES and MIXED The primary data used to answer this question come from three sources: qualitative interviews; a modified version of the Nurturing Scale from the Parents’ Behavior Checklist; and a set of questions that measured parents’ Child Development Knowledge. The questions were asked of



parents participating in PO 2 programs at intake and after participation in a First 5 Fresno-funded Home Visitation program. Evidence for improvements in parent knowledge and quality of parent-child interaction will come from increases in scores over time.

Secondary data were drawn from Core Participant Data (CPD) questions about the frequency of parent-child activities, such as reading. CPD questions were asked of parents at intake and every 6 months after that. Evidence for improvement come from increases in frequency over time as compared to the frequencies reported at intake.

Qualitative data indicate that the Home Visitation programs, whether a School Readiness/Family Connections program or a community-based organization (CBO) program, have been quite successful in changing parental behavior and understanding of their child’s development and learning processes. Both providers and parents agree it has been of value, improved parent-child interactions, and improved the school readiness of children (PO2). The only structural limitation of this program is that there are not enough services to meet the demand from providers and parents.

Many of the programs, by employing culturally and linguistically appropriate home visitors, have been able to overcome many cultural and linguistic barriers to preparing children for school entry into Kindergarten (PO3).

A quote from a Family Connections provider reflects changes in parental involvement:

Interviewer: What kinds of things have happened as a result of this program? Provider: There was one parent who was actually beginning to read to his children now. …He didn’t do it before because he was embarrassed. It wasn’t in their culture. And now the family educator was teaching them the difference. … We have seen more father involvement. … And it was great because …the dad was there and he was like, “Oh look I didn’t know we could do this!”… [Dads] have seen that you can get on the floor and you can play with the blocks; and they can do that…It doesn’t have to be reading or…academic kinds of things. [SR Provider]

From CBO providers, changes reported among Hmong parents include both increased parental involvement, and changes in their conceptualizations of when a child can learn and accept teaching lessons:

The particular challenges are the [Hmong] parents themselves have a different approach to education. They believe it belongs in the hands of the school alone, right? [They feel:] “They’re the teacher, what do I know?” So we are trying to push this idea that we are “partners in education”… and there’s kind of another piece because they don’t think that children learn that well when they are younger, so why bother at that age… Because [they’ve] never had a culture of going to school, so because [they] never have a culture of going to school, they don’t see the importance of it. That’s why when we have a preschool, [they] start seeing the importance of it. [SR Provider]

A Hmong parent confirms this belief regarding the teaching of young children:

Oh, according to the Hmong way of educating, small children are not yet taught … because when a child is too small, Hmong people…say: “The child is still too young to be able to learn.” So the children did not learn anything… Under the


ages of 5 or 6, [parents] still say that they are small children [incapable of learning such tasks]. [SR Client]

Quantitative data measuring parents’ knowledge of child development and practice of child development also indicated improvements, while data measuring improvements in the quality of parent-child interactions were mixed:

• Did parents’ knowledge of child development increase after participation in First 5 Fresno-funded programs? YES o Six Child Development Knowledge (CDK) questions tested parents’

understanding of basic child development (e.g., Question: “When do you think a parent can begin to significantly impact a child’s brain development, for example impact the child’s ability to learn?”; Answer: “Prenatal”). Parents’ answers to these questions were scored for correctness, and then summed to create a CDK score that ranged from 0 (no questions right) to 6 (all questions right).

o PO 2 programs: YES, but not significant 12 parents had answered CDK questions at intake and at least one other

time after participating in a First 5 Fresno-funded PO 2 program in FY 05-06. Their average score at intake was 3.8 questions out of 6 correct. Their average score after participating in a PO 2 program was 4.3 questions correct. While this increase was not statistically significant, it probably would have been had there been more parent data.

o PO 3 programs: YES 81 parents had answered CDK questions at intake and at least one other

time after participating in a PO 3 program in FY 05-06. Their average score at intake was 3.6 questions out of 6 correct. Their average score after participating in a PO 2 program was 4.9 questions correct. This increase was statistically significant at a high level, p<.0001.

• Did parents’ practice of child development increase after participation in First 5 Fresno-funded programs? YES o Three parent-child activity questions from the CPD questions asked about the

frequency that the child is read to or shown picture books, is sung songs with, and is told stories. Statistical analyses compared the number of parents who have increased the frequency with which they did these activities with their children versus the number of parents who have decreased the frequency with which they did these activities with their children.

o PO 2 programs: YES Reading or showing picture books: 92 parents had data both at intake and

at least one time after participation in a PO 2 program. 62 parents increased their frequency, and only 7 parents decreased their frequency, which results in a highly significant increase in frequency overall, p<.0001.

Singing songs: 82 parents had data both at intake and at least one time after participation in a PO 2 program. 25 parents increased their frequency, and only 7 parents decreased their frequency, which results in a moderately significant increase in frequency overall, p<.011.



Telling stories: 81 parents had data both at intake and at least one time after participation in a PO 2 program. 19 parents increased their frequency, and 14 parents decreased their frequency, which results in a barely significant increase in frequency overall, p<.046.

o PO 3 programs: YES Reading or showing picture books: 518 parents had data both at intake

and at least one time after participation in a PO 3 program. 200 parents increased their frequency, and 94 parents decreased their frequency, which results in a highly significant increase in frequency overall, p<.0001.

Singing songs: 366 parents had data both at intake and at least one time after participation in a PO 3 program. 117 parents increased their frequency, and 39 parents decreased their frequency, which results in a highly significant increase in frequency overall, p<.0001.

Telling stories: 359 parents had data both at intake and at least one time after participation in a PO 3 program. 151 parents increased their frequency, and 59 parents decreased their frequency, which results in a highly significant increase in frequency overall, p<.0001.

• Did the quality of parent-child interaction increase after participation in First 5 Fresno-funded programs? MIXED o Quality of parent-child interaction was measured by parents’ answers to a

series of questions that were modified from the Parents’ Behavior Checklist (PBC). Questions were taken from the Nurturing scale and scored and summed according to the PBC manual. The final score ranged from 1 to 4, with 1 signifying low nurturance and 4 signifying high nurturance.

o PO 2 programs: NO 45 parents had answered PBC questions at intake and at least one other

time after participating in a PO 2 program in FY 05-06. Their average score at intake was 2.7, and their average score after participating in a PO 2 program was 2.6. This decrease was statistically significant at a moderate level, p<.03.

o PO 3 programs: YES 202 parents had answered PBC questions at intake and at least one other

time after participating in a PO 3 program in FY 05-06. Their average score at intake was 2.8, and their average score after participating in a PO 2 program was 3.0. This increase was statistically significant at a high level, p<.0001.

Additional evidence comes from a Project Annual Evaluation Report (PAER). The Malaga School Readiness Program’s PAER reports that parents found that they gained knowledge and skills, which empowered them to seek resources for the betterment and well-being of their families.

Did services have impacts on children’s developmental progress and well being? YES, mostly increases in children’s developmental progress

The primary data source for the answer to this question is the Ages and Stages Questionnaire


(ASQ). Parents reported on their children’s development using the appropriate ASQ form for their child’s age at intake and every 6 months thereafter. Evidence for improved developmental progress comes from increases in children’s relative position on the large distribution of scores used to norm the ASQ.

• The Ages and Stages Questionnaire is a widely-used screening instrument that uses a series of age-linked forms with developmentally-appropriate questions to determine whether a child is developing within normal ranges. Each form (there are 19 forms that cover the age range from 4 to 60 months) asks age-appropriate questions about children’s development. o Each form results in 5 scores that each range from 0 to 60: Communication;

Gross Motor; Fine Motor; Problem-Solving; and, Personal/Social. o These scores were then transformed using means and standard deviations

from the ASQ norming sample for that age form so that they show how high a child’s score was relative to the general population of children at that age.

o These new, normed, scores could be: negative, meaning that the child’s score was lower than the general population of children at the same age; positive, meaning that the child’s score was higher than the general population of children at the same age; or zero, meaning that the child’s score was the same as the average score for the general population of children at the same age.

o Improvements in developmental progress are demonstrated by increases in a child’s normed scores over time. For example, if a 10 month old child’s normed Gross Motor score is -0.4 at intake (which means that their Gross Motor score was somewhat lower than the average scores of 10-month-olds in general), but was -0.2 at the one year follow-up (which means that their Gross Motor score was only a little lower than the average scores of 22-month-olds in general), that would indicate a positive increase of 0.2 standard deviations in their Gross Motor development. While their score of -0.2 is still a little below the average for all 22-month-olds, it indicates a personal increase for that child, a positive outcome.

• PO 2 programs: MOSTLY INCREASES, but only 1 significant o 55 children had ASQ scores at intake and at least one time after participating

in a PO 2 program in FY 05-06. Their average normed ASQ scores at intake and at follow-up, as well as the change from intake to follow-up are shown in Table 3.13 below. While only one scale, Fine Motor, showed a significant increase, 4 of the 5 scales showed increases. Only Communication showed a slight decrease. Table 3.14: ASQ Scores for Children in PO 2 Programs

Average Normed ASQ Score

ASQ Scale Intake Follow-up

Change from Intake to Follow-up

Communication 0.04 -0.10 -0.14 Gross Motor 0.39 0.44 +0.05 Fine Motor* -0.32 0.20 +0.52 Problem-Solving -0.39 -0.01 +0.38 Personal/Social -0.15 0.10 +0.25

* Significant at p<.05.



• PO 3 programs: MOSTLY SIGNIFICANT INCREASES o 166 children had ASQ scores at intake and at least one time after

participating in a PO 3 program in FY 05-06. Their average normed ASQ scores at intake and at follow-up, as well as the change from intake to follow-up, are shown in Table 3.14 below. Four of the five scales showed significant increases, and the one non-significant scale, Gross Motor, still showed an increase. Table 3.15: ASQ Scores for Children in PO 3 Programs

Average Normed ASQ Score

ASQ Scale Intake Follow-up

Change from Intake to Follow-up

Communication* -0.65 -0.36 +0.29 Gross Motor 0.06 0.08 +0.02 Fine Motor* -0.16 0.08 +0.25 Problem-Solving*** -0.99 -0.52 +0.46 Personal/Social** -0.03 0.22 +0.25

* Significant at p<.05 ** Significant at p<.01 *** Significant at p<.001

Again, additional evidence may be found in a Project Annual Evaluation Report (PAER). According to the Khmer Society of Fresno’s PAER, children’s self-esteem and interest in playing and leadership in play activities, as well as motivation, has increased due to their participation in the program. Many children when they started the program were timid and fearful of interacting with adults and other children.

Has First 5 Influenced providers serving low API areas to adopt and implement home visitation best practices? YES

Qualitative evidence shows that programs in this initiative use a variety of best practice techniques (e.g., home visiting, culturally and linguistically-appropriate approaches and materials) to reach and educate parents in the target populations. Stone Soup runs a preschool for Southeast Asian refugees of Hmong and Lao origin. However, the preschool also enrolls children from other backgrounds. The preschool plays a role in helping children acculturate to the school setting and with screenings. Khmer Society has a community-based home visitation program and is in the process of obtaining accreditation to open a preschool. The home visits help Khmer families and children learn about the importance of early education and encourage them to enroll their children in preschool. Both Khmer and Stone Soup work with parents to help them understand the importance of early care and education for their children. They also try to address cultural and social norms that may prevent or hinder the parent’s role in supporting their children’s preparation for school.

FIRM (Fresno Interdenominational Refugee Ministries) is a local faith-based ministry, building communities of hope for refugees by offering job training and assistance, citizenship classes, elder assistance, and a variety of services that include a preschool and home visitation service for children 0-5. They serve a variety of ethnic populations.


Another example of First 5 Fresno’s efforts to encourage providers to adopt best practices was the coordination and facilitation of monthly ECE provider meetings, in which SR coordinators and Home Visitors both networked and received information and training on best practices.

Has First 5 improved access to school readiness and transition services by creating a network of coordinated ECE providers in targeted low API areas? Have funded providers improved system coordination, communication, and efficiency? YES Qualitative data indicate that First 5’s initiative in creating multi-dimensional School Readiness programs such as the addition of K-Camps, preschool, and/or home visitation has improved communication and referrals between ECE providers. ECE providers reported that networking helped develop common ground for troubleshooting and coordination of services for children and their families. It is worth noting that providers also reported that those administrators not familiar or supportive of School Readiness programs become supporters as they experience increased parental involvement because of the School Readiness programs. One provider stated:

We really do appreciate the fact that they [First 5] have involved the providers, us. … We feel the support. … It’s not top down, where they are forcing us to do these things and we don’t have a say. We are working together for the betterment of our families. [SR Provider]

Further evidence comes from the West Hills Community College/Child Development Centers PAER. They state that the Family Connections project helps connect families, who are seeking assistance for their child, to agencies that will provide that support. This process is time intensive. Family Connections collaborates with parents to develop a portfolio of materials about their child as an innovative method of helping parents keep information that is typically requested by agencies all in one location. Family Connections also works with the agencies providing support to the family by making sure that all agencies are talking to one another at the outset and throughout the coordination and assessment process.

A common theme running throughout PAERs in the School Readiness and Family Connections initiatives is that collaboration among agencies is a key to successfully reaching targeted populations. Therefore, the School Readiness and Family Connections initiatives are just two examples of how funded agencies are reaching out to the provider community to create a coordinated network of ECE providers. For example, one School Readiness program had a community fair specifically to invite other providers and service agencies to participate and learn about school readiness. Other School Readiness programs work to coordinate services among school and health agencies to support parents’ needs to gain information and education on a variety of early childhood education topics. There are also referrals between agencies that are being provided, making the connection between those providers even stronger.



Are K-camp children better prepared to enter Kindergarten as a result of the service? Do they benefit as a result of K-Camp participation? YES Evidence for the answer to this question comes from qualitative focus groups and interviews. Two K-camps were visited for qualitative targeted studies: Calwa and Lowell Elementary Schools. Two coordinators were interviewed for both K-camps. Five staff from Lowell were interviewed and three at Calwa. Five Calwa parents were interviewed and seven Lowell parents were interviewed. All were Latino parents.

Calwa is a rural/urban community on the outskirts of Fresno with a population just less than 1000 people year round. Calwa is considered a low Academic Performance Index (API) area. Most of the residents are Latino (94.6% according to U.S. Census data). Almost all children attending K-camp are Latino, except for a few Hmong and African American children. Providers

highlighted the importance of K-camp, indicating that for many of them, this was their only opportunity to access a transitional program before entering Kindergarten.

Lowell K-camp took place at Lowell Elementary, close to downtown Fresno. Lowell is located in an area whose residents are generally below the federal poverty level and which is considered one of the high crime areas in Fresno. Despite the

unstable environment of the neighborhood where Lowell K-camp takes place, providers indicated that parents participate in meetings and are very engaged with the education of their children. Lowell is also a School Readiness Program, with a home visitation component.

The evaluation sampled the K-camps since they are central to the goals of Priority Outcome 3. Both providers and parents were enthusiastic about this program in terms of delivering “responsive, developmentally-appropriate enrichment experiences.” From both the providers’ and the parents’ perspective, the K-camps were extremely important to the maturation and school readiness of children prior to entering Kindergarten. The only major limitation of this program reported was that it could not be offered for more children in more schools.

Providers reported seeing children gain confidence and skills. One K-Camp provider stated:

After they attend [K-Camp], they are more confident, more prepared. Without K-camps, the teacher has to work a lot on fine/gross motor skills. Parents don’t work on developing these skills. Kids who go to K-camps know how to hold a pen, know how to draw, color, get along with other children, sharing—learning those things. [K-Camp Provider]

In addition, the K-camp providers heard from Kindergarten and other teachers that K-camp children were better prepared than other children and do better academically, as well:

This is my third year…that I have worked with the camps and I personally receive really good feedback from kindergarten teachers who have expressed how good they feel. How well the children are, coming to the first day, and how well they have adapted…So the fact that the kindergarten teachers acknowledge that, it makes me feel that it’s worthwhile and we’re making progress, that’s very beneficial. [K-Camp Provider]


Yet another provider stated:

We have gotten some feedback that our children that are now in first and second grade are being acknowledged as student of the month or maybe getting a perfect attendance certificate. So that’s the feedback. And I think it has to do with the amount of parent involvement. [K-Camp Provider]

Parents are included in the educational mix. K-camps involve parents in the teaching and learning experience which in turn, as noted above, helps the children. A provider elaborates:

The community is very poor and the majority are Hispanic, like 90% are Hispanic. What helps a lot is that we try to involve the families. Many of these families do not get involved a lot. But with these programs, we try to get them to participate by inviting them to participate. We organize various activities at least twice per week; we organize workshops and invite them to come. We really have involved many parents and they have gotten to know each other. Even if they live here [in the neighborhood], they don’t know each other. I don’t know why, if it is because of culture or education, but through the program they do now. They are getting involved a lot more with the school and with their children’s education. When we educate the children, we also educate the parents so that they in turn can help their children succeed. [K-camp Provider]

Parents appreciate learning how to be teachers with their children:

To me personally, it has helped me. With my older children, I never really had the opportunity to sit with them and tell them, “My children, I’m going to teach you the colors,” something like that. But with my younger daughter, the one who is coming to K-camp, I had a lot of opportunity to engage her more and talk to her and take her places more. My other children tell me, “How come you did not do those things with us?” And I tell them, because before, I did not know. Now, I know better and know that this program is really helping her and I can help her too. [K-camp Client]

Parents also report positive changes in their children that they support and cannot always teach themselves:

They learn a lot. …Many of the children do not come to K-camp and they go directly into ‘Kinder’ [Kindergarten] and they don’t know much because in all honesty many of us as parents do not have the time to teach them at home. We help them with the basics, like doing homework, but to be helping them specifically with, like, colors, we really don’t have time. So then this program helps in teaching them the things that we can’t teach them. They do better in school. [K-camp Client]

School readiness includes pre-reading skills such as holding the book properly, telling stories from the pictures, and being excited about books. Two different parents report this:

Parent #1: My child likes to look through the books even though she does not read yet. She tells me, “Look mom,” and tells me the story of the book just by looking. She pretends she is reading…In my opinion this program helps children a lot because when they enter Kindergarten, they are going to be more advanced than other children. [K-camp Client]



Parent #2: Now, he reads and browses through books and asks me to read to him, and he wants to read to me too. He can’t read yet but he likes to pretend. I have noticed a lot of changes on my child. He is still hyperactive but still likes the activities. He talks more. [K-camp Client]

In addition, maturation was seen by the parents:

It helps them be more confident. They know they are going to school and it helps them with anxiety…It also helps them with sharing with other children. My child would not share before, he did not like to share because he did not know with whom. Now he begins to share more…They get better prepared. It helps them to respect more and obey instructions. [K-camp Client]

Overall, providers indicated that participation in K-camp has demonstrated that children do better in Kindergarten. Some providers also indicated that children do extremely well beyond Kindergarten as they have seemed to have excelled in primary education, particularly those that received home visitation and then attended K-camp. Of interest, they also indicated that in their experience, children attending the local non-First 5 Fresno preschool did not bring the necessary skills to Kindergarten activities.

Across several of the K-camp PAERs providers have noted that children who have participated in K-Camps show a noted difference from children who have not participated in K-Camps, particularly those from immigrant communities in Fresno County. Kindergarten teachers note that children from K-Camps are more confident in their own ability to socialize and participate in group activities, as well as have familiarity with basic activities that children are expected to be a part of in Kindergarten classes.

3.7 Summary and Conclusions The process and outcome data gathered on activities pertaining to the Early Care and Education priority can be summarized as follows.

3.7.1 Process Evaluation Of the 31 programs addressing Early Care and Education, most (25) did so by providing Direct Services. These 25 reported providing 11,500 unduplicated clients with 42,417 service contacts, the majority of which (22,935) were with children 0-5 years of age, the largest percentage of whom (almost 80%) were Latinos. Direct Services were most commonly provided as classes or workshops, although in-person consultations or services, case management, and home visits were also frequently used service modes.

Systems Change Support was the next most common form of program activity. Although the kinds of activities funded were highly diverse, the most common forms of supporting systems change were organizing meetings to share information and coordinate decision making, developing materials for diverse populations, and supporting interagency collaboration.

Provider Capacity Building programs focused almost equally on providing training for serving clients with disabilities and special needs, addressing cultural diversity, dealing with licensing and accreditation issues, and ways of supporting school readiness, as well as a number of distinct issues.


Community Strengthening Efforts, of which there were comparatively few, focused on organizing community events and, in only one instance each, organizing community associations or networks and conducting a media campaign. Finally, only one program focused on investing in physical infrastructure.

3.7.2 Outcome Evaluation

Priority Outcome 1: Quality Infant-Toddler Care Quantitative, qualitative interview and focus-group data gathered by LTG provides answers to the key evaluation questions pertaining to Infant-Toddler Care:

1. Have providers/agencies improved their quality of childcare? Yes, with the greatest improvements coming from advanced training.

2. Have First 5 funded efforts…contributed to improvements in providers’ ability to provide quality care for children?

Yes, but providers wish for timelier training enrollment and more slots.

3. Have providers/agencies changed the way they work to maximize efficiency and access to services through childcare providers for (1) all children and families; (2) children with health needs; and, (3) children with special needs?

Yes, with the exception of speech therapy.

The results of the Child Health Care Linkages PAER also lend their weight to an affirmative answer to the latter of these two questions.

Priority Outcome 2: Parent/Caregiver Support; and, Priority Outcome 3: Utilization of Enrichment Services A variety of quantitative and qualitative data helped the evaluation answer six key questions. With the exception of a few aspects of the larger questions on which the data provided mixed or inconclusive outcomes, the evaluation data answer the following questions in the affirmative.

1. Have First 5-participating parents/caregivers improved their knowledge and practices of child development and improved the quality of parent-child interactions?

Improved knowledge, improved practices of child development, mixed results for quality of parent-child interactions.

2. Did services have impacts on children’s developmental progress and well being? Yes, mostly increases in children’s developmental progress.

3. Has First 5 influenced providers serving low API areas to adopt and implement home visitation best practices?

Yes.

4. Has First 5 improved access to school readiness and transition services by creating a network of coordinated ECE providers in targeted low API areas? Have funded providers improved system coordination, communication, and efficiency?

Yes.



5. Has First 5 improved access to ECE services? Has understanding, access, and utilization of preschool and ECE services improved for parents/caregivers from communities that may not be as familiar with these services because of cultural and/or linguistic characteristics?

Yes.

6. Are K-camp children better prepared to enter kindergarten as a result of the service? Do they benefit as a result of K-Camp participation?

Yes.

Findings, Strengths, and Challenges from Qualitative Data In addition, qualitative data on Overall School Readiness, Home Visitation, and K-Camps efforts yield a useful catalog of findings, strengths, and weaknesses of these activities, as follows.

Findings

• Capacity building was achieved through education and information sharing for school personnel, parents, and the larger community.

• Home visitation pre-school programs introduce the whole family to new ways of teaching, learning, and socialization.

• Community-based organizations’ home visitation programs reach specialized populations, such as Hmong, with programs to address culture-specific barriers to early learning and teaching.

• Rural schools have been able to increase their capacity to prepare children successfully for school.

• Kindergarten camps (K-camps) are a bridge from pre-school to kindergarten for those children who have been to pre-school and provide an introduction to schooling and context for socialization for those who have not.

• Limited qualitative responses from Kindergarten teachers and other teachers report that children who have been through First 5 Fresno home visitation, early child enrichment, pre-schools, or K-camps, perform better in school than those who have not.

• Parents were very satisfied with programs, reporting that their children were more mature, confident, and better prepared for school through participation in these programs.

• Parents reported changes in their own teaching, learning, and nurturance with both the target child and other children in the family.

• The ripple effect is quite apparent: parents reported that what they learned through participation in these programs, they taught to other parents and relatives, e.g., grandparents, and was used with other offspring.

Strengths

• A coordinated, multi-dimensional approach prepares children for school structure and curriculum.

• Flexibility of funding allows individual schools and organizations to develop approaches specific to their service or catchment populations.


• Bilingual and bicultural home visitors and teachers make school and the whole learning process more accessible to immigrant and refugee families.

Challenges

• There were more applicants than slots open for families and children. • More integrated programs were needed within each school so that preschool,

home visitation, and K-camp programs could be available in each low API school. Not all low API schools have a School Readiness program or Home Visitation program. Some have one component but not the other.

• There are many barriers to parent participation, including the following. o Preschool costs of non-FF programs. o Lack of transportation. o Lack of parental awareness of need. o Linguistic barriers and cultural norms. o Beliefs that parents should not interfere in school-related domains, such as

learning and teaching. o Cultural issues about child development that consider early education

detrimental to the child, who is thought not ready to learn prior to kindergarten.

o Different perceptions of proper learning, particularly the ideas that learning is accomplished through repetition and rote learning and that having fun while learning is contradictory to good teaching.



Chapter 4 PRIORITY AREA: HEALTH

4.1 Introduction The central goal for this Priority Area is to ensure children’s health as an important component for school readiness. First 5 Fresno has employed a focused approach to meeting this goal by concentrating on a few targeted areas.

One of the most substantial barriers to health care for children, if not the most substantial, is lack of health insurance. Therefore First 5 is committed to ensuring that every child 0-5 in Fresno County has health insurance. An important step toward this goal is to raise awareness of preexisting programs such as Medi-Cal and Healthy Families and to facilitate children’s

enrollment into them. Additionally, First 5 has established a health insurance program for those children that do not qualify for preexisting programs. The reduction in the number of children who do not have health insurance means that more children will have the opportunity and access to consistent medical homes and preventive care. This in turn will increase their quality of life and enhance their readiness for school.

Programs in this Priority Area also facilitate education for providers and parents to create awareness about children’s medical needs and the services available.

In FY 05-06 First 5 Fresno funded six programs under the Health Priority Area for a total of $864,428.00. These programs encompass the following Priority Outcomes:

Priority Area: Health

Priority Outcome 4: Reducing Financial Access Barriers to Health Care Increase the ability of families to access health services by reducing financial barriers to care.

Priority Outcome 5: Supporting Utilization of Health Systems/Care Increase the number of children 0-5 utilizing a consistent medical home for regular preventive, or well-child care, and treatment.

Priority Outcome 6: Supporting Children with Behavioral, Developmental, Emotional, Mental Health, and Special Health Needs through Primary Care Increase the capacity of health care providers to support the behavioral, developmental, emotional, mental health, and special health needs of children and link them to available sources of care.

Priority Outcome 7: Family Knowledge and Education Increase the number of parents who are knowledgeable in supporting the health needs of their children and accessing needed services, with an emphasis on systems level efforts with broad scale impacts.


4.2 Area Overview First 5 Fresno is providing specific health interventions through at least four Priority Outcomes: 4, 5, 6, and 7. Priority Outcome 4 seeks to increase the ability of families to access health services by reducing financial barriers to care, while Priority Outcome 5 focuses on ways to increase the number of children 0-5 utilizing a consistent medical home for regular preventive, well-child care and treatment. Both Priority Outcomes 4 and 5 are the cornerstones of the Children’s Health Initiative (CHI), to be discussed in section 4.2.2.

Priority Outcome 6, which is to increase the capacity of care providers to support the behavioral, developmental, emotional, mental health, and special needs of children and link them to available sources of care, was not funded during FY 05-06. However, at least one program remaining from previously funded strategic health efforts is thematically listed in the following section (4.2.1). Most funding under PO6 was awarded during the 2006-2007 Fiscal Year and will be reported as such.

Similarly, there was limited activity within Priority Outcome 7, focusing on increasing the number of parents who are knowledgeable in supporting the health needs of their children and accessing needed services, with an emphasis on systems level efforts with broad scale impacts, for FY 05-06. In addition, the CHI Media Campaign is also listed under Priority Outcome 7. First 5 Fresno did fund a primary intervention in support of the Children’s Health Initiative, cited under Priority Outcomes 4 and 5.

4.2.1 Program Listing and Expenditures Table 4.1: Health Priority Area Program Listing and Expenditures

Children’s Health Initiative

Contract Program Priority

Outcome FY 05-06 FFF Expenditures

2005CP6033 CHI-OERU PO 4&5 $304,152.00 2005PA6024 Program Admin-CHI PO 4&5 $111,264.00 2005PA6042 CHI-Enrollment Processing PO 4&5 $230,199.00 2005PA6043 CHI Media Campaign PO 7 $82,921.00

Other Health Programs

Contract Program Priority

Outcome FY 05-06 FFF Expenditures

2002CP6511 Pediatric and Specialty Genetic Services Project PO 6 $99,878.00 010C01 Early Childhood Caries Prevention Project PO 7 $36,014.00

4.2.2 Children’s Health Initiative It is estimated that Fresno County has about 26,000 uninsured children.7 The Children’s Health Initiative (CHI) of Fresno County was launched in September 2005 as a multi-agency effort to increase the number of children 0-5 in Fresno County with health insurance. The initiative is the 7 Fresno Healthy Kids Member Handbook. Additional information can be found at the Institute for Health Policy Solutions’ Report: Data and Recommended Strategies for Expanding Health Coverage to Children in Fresno County. The report can be found at http://www.ihps-ca.org//publications/_pdfs/FresnoSiteVisitFINAL.pdf



result of a multi-year planning process involving community members, community agencies, and other stake-holders. CHI also covers children 6 to 18 years of age, utilizing funding from other sources, primarily the California Endowment, Blue Shield Foundation and Kaiser Permanente.

CHI was funded under Priority Outcome 4 and 5, with the goals: “increase the ability of families to access health services by reducing financial barriers of care;” and, “increase the number of children 0-5 utilizing a consistent medical home for regular preventive, well-child care and treatment.” This is implemented by offering enrollment opportunities for existing state sponsored programs such as Medi-Cal and Healthy Families and by ensuring that children not qualifying for those insurance programs can access other local health programs, including Kaiser Permanente and Healthy Kids.

The Fresno Healthy Kids program, which is directly covered through First 5 Fresno funding, offers low cost insurance for children 0-5 (as well as children 6 to 18 years old, who are covered by other sources) living in Fresno County. This low cost insurance provides health, dental, and vision coverage to children who meet the program qualifications and are not eligible, or do not qualify, for full services through no-cost Medi-Cal and/or California’s low cost Healthy Families program.

In order to be eligible for the Healthy Kids program in Fresno County, a child must meet all of the following:

• Age 0 through 18 (up to their 19th birthday); • In a family with income at or below 300% of the Federal Income Guidelines; • Living in Fresno County; • Without employer-paid health insurance in the last three months; • Not eligible for no-cost, full scope Medi-Cal or for California’s low-cost Healthy

Families Program; and, • Pay a small premium.

The monthly premium is determined by the family’s income and can be from $4.00 dollars per month per child to a maximum of $15.00 dollars per month per child. The monthly premium is waived for families with a family income below 133% of the Federal Income Guidelines.

One of the results that the CHI hopes to show is: 1) children with health insurance are more likely to obtain the services and care that they need; and, 2) children with health care will be healthier throughout their lives. Access and enrollment in the health programs under CHI, along with retention efforts, will be key indicators of the success of the initiative.

4.3 Program Descriptions The Children’s Health Initiative (CHI) relies on two lead programs to carry out its mission: the California Health Collaborative; and, the Central California Legal Services (CCLS). Both programs aim to help children grow up healthy.

Under the direction of CCLS, 12 selected agencies in the County provide outreach and enrollment opportunities for families. Together they form the Outreach, Enrollment, Retention and Utilization (OERU) partnership. They provide outreach and information, and they enroll families into existing health insurance plans: Medi-Cal; Healthy Families; Healthy Kids; and,


Kaiser Permanente. For its part, the California Health Collaborative administers the health contracts and the Healthy Kids insurance program.

The California Health Collaborative contracted with Health Net, Delta Dental, and Safeguard vision insurance plans to provide medical, dental, and vision coverage. In addition to serving as the administrator for CHI and administering Healthy Kids, the California Health Collaborative created the infrastructure for effectively managing and processing premiums, as well as other demands associated with introducing and enrolling children into the Healthy Kids program.

There are several benefits to families that both programs promote and provide beyond enrollment. For instance, families not only have access to enrollment in health insurance but they are educated about the importance of having health insurance as a safety net to help their families stay healthy. They also educate parents about when and how to best seek care for their families. These lessons begin at the intake session with the OERU partners’ intake counselor and continue throughout the process of enrollment and follow-up. Even the enrolled children are taught about the importance of regular preventive health care and its impact on their lives, providing them with information that will encourage a lifetime of health awareness and action.

In addition to providing health education and assistance with health insurance enrollment, most programs actively referred children to other organizations or services. This included other health, developmental, and social service referrals.


4.4.1 Program Location Map Figure 4.1 shows the location of all Health programs throughout Fresno County funded in this Priority Area for FY 05-06.

4.4.2 Program Service Area Map Figure 4.2 shows program service areas, defined by program report of Zip Codes that they serve, for all Health programs funded in this Priority Area for FY 05-06.

4.5 Process Evaluation This section presents process evaluation data for programs in this Priority Area (Health) collected through State Aggregate Data (StAD) forms (collecting separate data on Community Strengthening Efforts, Direct Services, Provider Capacity Building, and Systems Change Support). Because these data are reported to the State First 5 Commission separately, they will be presented with little interpretation.



Figure 4.1: Location of the Health Priority Area Programs in FY 05-06


Figure 4.2: Zip Codes Served by Health Priority Area Programs in FY 05-06



There were a total of six programs addressing Health issues in this Priority Area. As Table 4.2 shows, programs targeted community strengthening activities, direct services to clients, and providing systems change support. In interpreting the following data it is important to remember that each program may have submitted more than one State Aggregate Data form, depending on their program activities. For example, the same program could have submitted one Direct Services form and one Infrastructure form. Table 4.2: Health Priority Area, State Aggregate Data Form Summary


Programs Turning in

Form* Community Strengthening Efforts 3 Direct Services 3 Provider Capacity Building 2 Systems Change Support 3 * A program can turn in multiple forms.

The next two tables summarize statistics from the three programs submitting Community Strengthening StAD forms. Table 4.3 shows that Media Campaigns and Public Speaking were the modalities used most. Table 4.3: Community Strengthening Modality


Est. Size of Audience

Community events, celebrations, fairs 1 5,230Information dissemination 1 1,150Media campaigns 2 4,363,966Public speaking 2 64Other community strengthening efforts 1 250

Table 4.4 shows that the most common topic covered by programs (programs could report more than one) was Preventive Health Care for Children. Table 4.4: Community Strengthening Topics


Community resource awareness 2 Safety education and violence prevention 1 Prenatal care 1 Breastfeeding 1 Nutrition 1 Preventive health care for children 3 Positive parenting practices 2 Peer support networks 1 Other community strengthening topic 2

The next five tables summarize statistics from the three programs submitting Direct Services StAD forms. Table 4.5 shows that First 5 Fresno Health programs providing Direct Services to clients in FY 05-06 served 3,766 clients and provided more than 4,000 service contacts to clients, more than 1,500 of which were to children aged 0-5 years old.


Table 4.5: Direct Services Unduplicated Counts and Service Contacts


Service Contacts

Directly-served Children 1,525 1,655Indirect service to Children 134Parents/Guardians 281 738Other 1,960 1,971Total 3,766 4,498Table 4.6: Direct Services Service Contacts by Client Demographic

Children 0-5 Parents/Guardians


Contacts %Service


American Native 1 0.1 1 0.1Asian 49 3.0 13 1.8Black 16 1.0 3 0.4Latino 1,313 79.3 446 60.4Other 118 7.1 16 2.2Pacific Islander 13 0.8 5 0.7Unknown 25 1.5 75 10.1White 120 7.2 179 24.2Total 1,655 100.0 738 100.0

# of Service Contacts by LANGUAGE English 456 27.6 378 51.2Hmong 8 0.5 7 0.9Other 12 0.7 10 1.4Spanish 641 38.7 341 46.2Unknown 538 32.5 2 0.3Total 1,655 100.0 738 100.0


# of Service Contacts by AGE OF CHILD Served Directly Children 0-3 588 35.5Children 3-5 1,058 63.9Age Unknown 9 0.5Total 1,655 100.0Served Indirectly through Parent/Guardian Children 0-3 64 3.1Children 3-5 70 3.4Age Unknown 1,939 93.5Total 2,073 100.0



In Table 4.6 service contacts are categorized by several client demographic factors. As was true for the Early Care and Education programs in the last chapter, the majority of service contacts for children were to Hispanic/Latino children (79.3%, an increase of 27% from FY 04-05), children who primarily spoke Spanish (38.7%, a slight decrease from FY 04-05), and children who were between the ages of 3 and 5 years old (63.9%, an increase of 13% over FY 04-05). Children who have special needs, a small percentage of the population, received 8 direct service contacts, and 1 indirect service contact through parents and others.

Table 4.7 shows that the most frequently used modality for Direct Services was In Person, providing more than 1,600 contacts for children. Table 4.7: Direct Services Modality


Modality

Programs Using

Modality Service

Contacts %Service

Contacts % In-person consult/service 3 1,649 99.6 724 98.1 Public/community event 1 6 0.4 14 1.9 Total 1,655 100.0 738 100.0

The next two tables show data from the two programs submitting Provider Capacity Building StAD forms. Table 4.8 shows that the First 5 Fresno Health programs providing Capacity Building services provided 266 service contacts to providers. Again, it is important to note that the figures in the following tables represent service contacts and not unduplicated counts of participants. Table 4.8: Provider Capacity Building Service Contacts by Type of Client Served


Contacts %Health care 11 4.1Family support 8 3.0Other 127 47.7Unknown 120 45.1Total 266 100.0

Table 4.9 shows the Provider Capacity Building training topics reported by the programs (programs could report more than one). Table 4.9: Provider Capacity Building Activity

Training Topic

Programs Covering

Topic Licensing/accreditation 1 Other 2

Three programs in the Health Priority Area completed Systems Change Support forms for FY 05-06. Table 4.10 shows the Systems Change Support activities reported (programs could report more than one).


Table 4.10: Systems Change Support Activity

Activity

Programs Engaging in

Activity Conducting research or evaluation 1 Meeting with/educating policymakers 1 Preparing documents to support policy changes 1 Other advocating for policy changes or new legislation 1 Writing proposals to request additional funds 2 Preparing/implementing sustainability plans 2 Other raising or leveraging of funds 2 Developing or monitoring service quality standards 2 Other service quality improvement 1 Developing programs/materials for diverse populations 2 Establishing or maintaining registries and databases 1 Organizing meetings to share information/coordinate/decisions 2 Organizing meetings among providers to coordinate cases 2 Other interagency collaboration 1 Universal health care or augmentation of health insurance 3 Other efforts to increase accessibility 1 Other systems change activities 1


4.6.1 Priority Outcome 4: Reducing Financial Access Barriers to Health Care; and, Priority Outcome 5: Supporting Utilization of Health Systems/Care

Because First 5 Fresno has always considered these two Priority Outcomes together, we will address outcomes for both POs in this same sub-section.

The goal for Priority Outcome 4 is: “[i]ncrease ability of families to access health services by reducing financial barriers to care.” The goal for Priority Outcome 5 is: “[i]ncrease the number of children 0-5 utilizing a consistent medical home for regular preventive, or well-child care, and treatment.” First 5 Fresno has addressed both these goals by funding the Children’s Health Initiative.

First 5 Fresno and LTG have determined that the key evaluation questions for these POs are:

• Has First 5 Fresno reduced financial barriers to health care in order to increase health access for children 0-5? Do more children 0-5 have health insurance coverage in Fresno County as a result of First 5 efforts?

• Have children covered as a result of CHI increased appropriate utilization of preventive and treatment services?

• Has First 5 Fresno increased organizations' capacity to enroll children into health coverage programs in the County?

• Are strategies to increase enrollment into coverage working?



• Has First 5 Fresno improved County capacity to identify uninsured children, enroll them into health coverage, and support utilization and retention/continuity of coverage? Has the particular organizational structure (administration, outreach, etc.) and Fresno CHI components played a unique role in facilitating improvements?

Has First 5 Fresno reduced financial barriers to health care in order to increase health access for children 0-5? Do more children 0-5 have health insurance coverage in Fresno County as a result of First 5 efforts? YES Evidence for the answer to this question comes from the PAER for the Children’s Health Initiative. The CHI administrator reported that since the inception of CHI “the program has submitted 299 applications for Medi-Cal, 170 applications for Healthy Families and have enrolled 170 children into Healthy Kids, a new subsidized insurance program for children ineligible for Medi-Cal or Healthy Families, due to documentation status or income.” She indicated that as a result of having insurance, “these 639 children now have access to affordable health, dental, and vision care and a steady medical home.” Figure 4.3: Children Enrolled by the Children’s Health Initiative

Have children covered as a result of CHI increased appropriate utilization of preventive and treatment services? YES, but there are some barriers to utilization Primary evidence for the answer to this question comes from utilization reports from Healthy Kids, Delta Dental, and SafeGuard Dental and Vision. Utilization data were not available for Medi-Cal or Healthy Families enrollees.

The Children’s Health Initiative Enrolled 639 Children in FY 05-06

46%

27%

27%

Medi-Cal

Healthy Families

Healthy Kids


• The utilization report for Healthy Kids, the First 5 Fresno-sponsored health insurance program, indicate that children did access preventive and treatment services in the five months of FY 05-06 that the program was active. Table 4.11 summarizes the services used by children 0-5 from February to June 2006 in the Healthy Kids program. Table 4.11: Healthy Kids Utilization in FY 05-06

Type of Health Service

Number of Services

Used Physical Exam (Well Visit) 16 Immunizations 47 Screenings 41 New Patient 13 Established Patient 48 Emergency Room 5 Other Services 28 Rx Filled 48

• Delta Dental’s encounter data indicates that children 0-5 had 43 office visits between March 16, 2006 and June 6, 2006. They saw 15 different providers.

• Finally, SafeGuard Dental and Vision reported that they performed one eye exam on a covered child 0-5 in the second quarter of 2006.

The CHI Project Annual Evaluation Report (PAER) noted that parents who were served by the OERU-CHC health coverage initiative expressed their satisfaction that their children were finally insured, and that “this empowered the parents to make good health decisions for their children.” They say that the intake process at OERU includes educating parents about health insurance, how to effectively use services that are made available through the health insurance plans, and some basic health care prevention steps that families can use to assess their need to visit a health provider.

Qualitative interviews provided important information about utilization and uncovered some client issues. For the qualitative evaluation, four CHI administrators were interviewed and four Certified Application Assistors (CAA) (see Table 4.12). Table 4.12: Qualitative Data Collection Activities for PO 4 and PO 5

Children’s Health Initiative (CHI) Qualitative Interviews & Focus Groups



Administrator Interviews 4 4 CAA Interviews 4 4 Client Focus Group 1 2 Client Interviews 3 3 Total 13

Providers directly serving clients (CAAs) indicated that although they encouraged parents to take their children in for services, they found that parents needed assistance and case management follow-up regarding how to choose doctors and how to make that first appointment. One CHI provider said:



…most of my families…as soon as they get their health insurance card, they call me and let me know they got it. And then they’ll call me and say, “Can you help me make an appointment?” And some of the families that don’t call me, I’ll call them. And then I’ll tell them, “Did you get your card?” “Yes I did.” “Have you made an appointment?” “No I haven’t”, “Well, would you like me to help you make an appointment?” “Yes!” [CHI Provider]

One of the consistent difficulties reported by parents during the interviews was finding the “right” medical home. Some parents experienced difficulties getting their children’s medical care needs met by the medical home to which they had been automatically assigned. Other parents who attempted to independently find a medical home reported they had difficulty finding offices with non-English speaking medical staff or office hours that accommodated their work hours. Not knowing where to go or whom to talk to about these problems aggravated their frustration. Nevertheless, parents indicated that they continued to take their children to the “medical home” assigned but desired more information to help them navigate the health care system. One example was provided by a parent of a 1- and 3-year old in a small rural town about 20 miles outside of Fresno:

When the insurance cards came, both came at the same time [for my two children]. The card that [omitted name] sent me had a date to start using it, and the one from Fresno arrived later. I ended up with two different dates to start using the cards. So I took them to [omitted name], and she told me that the ones she had sent me were the ones I should use, and I could use them anytime. So I started using them the same day, but there was confusion. The cards were not activated yet. I took my child to the doctor because he was sick, and [omitted name] had already told me that I could use them. So when I got to the doctor’s office, they saw my child and everything. It was not until the second time I went back that they said that the card was still not activated. It needed one more day. So they are charging me the first consult and it is $70.00. So from there all the problems started. Now the doctor is very mean, and he has not been nice to me since then. [CHI Client]

Another parent indicated:

When I got the package, I think there was [sic] instructions on how to pick the doctor. They had like a whole page on how to pick out the doctors. And the one thing that was kind of hard for me was, when I called all the doctors, it seemed like they were all under the same system. It was hard to just call the clinic and get an appointment. It was like I had to go through some kind of system or call somebody else, and they- or the doctor was too full already. They couldn’t accept me… And so I just picked randomly, ‘cause I didn’t know who, who to pick. [CHI Client]

It is clear that even for families who have with experience with insurance and services are available, clients also may still need help with complex utilization issues.


Has First 5 increased organizations' capacity to enroll children into health coverage programs in the County? YES, but One-e-App can be cumbersome Evidence for the answers to the next three questions comes from qualitative interviews and focus groups (see Table 4.12). The agencies involved in outreach utilize CAAs. These agencies have key connections to hard-to-reach communities throughout Fresno County. Some are positioned to reach rural areas, and others urban. Some target Southeast Asians, while others work in communities such as Mixteco, an indigenous group from Mexico. Yet others are located in schools and medical settings.

Three clients were individually interviewed: two Latino and one Russian. One client focus group of only two Mixteco speakers was convened.8 A translator was available for assistance.

CHI became operational in September 2005. Since then, CHI has been actively enrolling children and connecting them to a medical home. The successful implementation of the 1-800 telephone call line has served as a point of entry for parents as CHI has continued outreach efforts in the community. Answering calls is a task that all OERU organizations share and has remained a coordinated effort among the agencies involved, under the leadership of Central California Legal Services.

All CAAs (16 total) have received training on the requirements of the different health products available: Healthy Kids; Healthy Families; Medi-Cal; and, Kaiser Permanente. Based on information submitted to Healthy Communities Access Program’s (HCAP) electronic application system called One-e-App, the CAA can determine which health product is best suited for the child.

The CHI PAER noted that the OERU has provided training to sixteen CAAs, and seven CAAs have received follow-up training over the course of the last year. The training and implementation of a strategic plan to assist organizations in understanding their role and responsibilities in enrolling families into health coverage plans has been successful. Partnerships have also been established with outside agencies. Reaching out to new organizations in Fresno County continues the expansion of this initiative.

Not having the ability to add or change information in application forms once they were electronically submitted was perceived by CAAs to add to their volume of work. As one provider observed, sometimes improper data entry on the application, along with the inability to re-enter the data system itself to make timely corrections, resulted in delays in treatment for children:

We have identified at least 120 families who haven’t gotten member materials because the address was wrong. That’s not even [counting] all those with data wrong, those are just addresses. I could go on and tell you about misspelled

8 While this was not an optimal number for a focus group, in order to take advantage of the situation, the two clients were interviewed more as a discussion and joint interview rather than a formal focus group.



names, wrong birthdays. Wrong birthday means that [a] child doesn’t get seen. We’ve had providers turn them away, and say, ‘Well, this card says, this is the child who’s insured with this birthday, that’s not the same birthday that this child said.’ Wrong child! And refuse to give coverage even though that is the child we’re covering! The birthdays are the things we can catch at enrollment, or when we review the application because they have to provide proof of birth. So when they don’t match up, we can’t correct [it] even when we see it. We have no solution within the way our system is designed. [CHI Provider]

Are strategies to increase enrollment into coverage working? YES, but their success has strained CHI’s resources CHI Fresno has networked with other CHIs across the state. The California Health Collaborative Administrator for CHI has participated in state meetings and currently there is hope that a state ballot initiative may provide additional leveraged dollars to support CHI efforts statewide. At the local level, CHI has been actively disseminating information to the community, paying close attention to rural areas. Outreach information has been a key strategy that CHI has utilized in order to enroll children. Involving community members, local officials, and other stakeholders has also been crucial to the level of success so far achieved.

While there has been a mutual desire to sustain and implement coordinated efforts to keep CHI going, it has been difficult. One overriding difficulty has been keeping the balance between leveraged dollars and the needs of the community. At some point within the year, the CHI administrator had to impose enrollment restrictions on children 6 to 18 as the number of enrollments exceeded the budgeted premiums to cover them. This made it difficult for CAAs who expressed feeling frustrated about not being able to help “all children.” One CAA indicated, “It’s very difficult and heart-breaking to turn away the families when not all the kids can be included” [CHI Provider].

Has First 5 Fresno improved County capacity to identify uninsured children, enroll them into health coverage, and support utilization and retention/continuity of coverage? Has the particular organizational structure (administration, outreach, etc.) and Fresno CHI components played a unique role in facilitating improvements? YES, but partnerships can be difficult The CHI PAER reports that the Children’s Health Initiative for Fresno County has improved the capacity of organizations to enroll children into health coverage plans that are available to them. This has been accomplished by partnerships that CHI has established with County agencies, community-based organizations, clinics, hospitals, and schools through its Child Health and Disability Prevention (CHDP) gateway. Having these partnerships in place, and standardizing the intake process to provide a “no wrong-door” policy for families to get information and to apply for health coverage, has helped CHI reach out to families with children who need health insurance in Fresno County.

Many of the providers interviewed agree that one of the strengths of the Children’s Health Initiative in Fresno has been the level of commitment and participation of the many stakeholders and community members. Several providers cited the level of community involvement that was needed in order to establish a Children’s Health Initiative in Fresno, reporting that many community members and stakeholders met for over a year to develop a plan before being able to


present it to, among others, First 5 for funding consideration.

A well coordinated plan was essential, along with commitment from various local funders in order to balance available resources, particularly those regarding age limits for children 0-5, as well as for children 6-18. While First 5 provided all of the funding to cover outreach, enrollment, processing, and premiums for Healthy Kids for children 0-5, other funders, such as the California Endowment, Kaiser Permanente, and the Healthy Communities Access Program, brought additional resources to cover children 6 to 18.

In relation to communication, having so many agencies, without a clearly defined set of roles and responsibilities among agencies, created serious challenges for those involved. One of the participants spoke of the benefits and challenges of managing these programs as partnerships rather than as contractual relationships:

Collaboration is a very difficult thing. I think it’s part of the process, but I think in the end it’s what makes Fresno unique and hopefully it’s what makes ours stronger. There’s more at the table because they’re committed but I think that it poses challenges particularly to this office because we’re charged with coordinating something that we don’t necessarily have control of… [CHI Provider]

4.6.2 Priority Outcome 6: Supporting Children with Behavioral, Developmental, Emotional, Mental Health, and Special Health Needs through Primary Care

The goal of Priority Outcome 6 is: “[i]ncrease the capacity of health care providers to support the behavioral, developmental, emotional, mental health, and special health needs of children and link them to available sources of care.” Although First 5 Fresno did not fund programs specifically under PO 6 for FY 05-06, two programs funded under General Grants and PO 2, Healthy Steps for Young Children and California Reach-out and Read respectively, addressed PO 6 goals through training programs for primary care medical residents.

First 5 Fresno and LTG have determined that the key evaluation questions for PO 6 are:

• Has First 5 Fresno improved primary care providers' ability to identify, assess, treat, and refer children with special needs?

• Has First 5 Fresno strengthened the linkages and coordination between primary health care services and developmental/special needs services?

Has First 5 improved primary care providers' ability to identify, assess, treat, and refer children with special needs? YES Evidence for the answer to this question comes from both the PAER for the Healthy Steps for Children program and the PAER for the Reach-out and Read (ROR) program. The Healthy Steps PAER noted that:

Our future primary care doctors will be better able to respond to the challenges presented by the families they serve, who are often ill equipped to meet the needs of their children. They will be better able to identify [behavioral and



developmental] problems [of] children early and link them to care sooner, which we know results in improved outcomes. [Healthy Steps Annual Evaluation Report]

The Reach-out and Read PAER noted that after one mother’s child had been identified as having a special need. She was:

…quite thankful for the books that her sons received. She also says quietly and with pride that the nine year old is doing very well in school. He looks up and smiles in confirmation. This is particularly meaningful because a couple of years ago he had some emotional issues which he’s now overcome. [Reach-out and Read Final Evaluation Report]

Has First 5 strengthened the linkages and coordination between primary health care services and developmental/special needs services? YES Again, evidence for the answer to this question comes from both the PAER for the Healthy Steps for Children program and the PAER for the Reach-out and Read program. The Healthy Steps for Children PAER noted that the linkages and coordination between medical residents and the Children’s Health Center has been the result of the incorporation of the Ages and Stages Questionnaire (ASQ) into home visits by medical residents, but also innovative changes in clinic policy for the scheduling of appointments for clients, and improvement in the communication between residents and CHC staff about developmental and behavioral issues.

The Healthy Steps Fresno program helped to encourage coordination between medical residents and families by introducing the ASQ into its protocol during home visits. Residents observed that using this protocol during home visits helped families participate more in the screening process, as well as helped medical residents focus more on listening to the parents.

When the CHC coordinator observed barriers to medical care because of inconvenient appointment times scheduled for clients, changes were made to accommodate clients’ schedules.

The Reach-out and Read PAER noted that their Coordinator relocated her office to the Children’s Services Network site in an effort to optimize networking opportunities with other providers of early childhood services throughout the County. For example, they are working to identify ways to train personnel in First 5 funded agencies in rural areas about how to properly conduct assessments for the Reach-out and Read program while performing home visits and early childhood interventions.

4.6.3 Priority Outcome 7: Family Knowledge and Education The goal of Priority Outcome 7 is: “[i]ncrease the number of parents who are knowledgeable in supporting the health needs of their children and accessing needed services, with an emphasis on systems level efforts with broad scale impacts.” First 5 Fresno did not specifically fund programs under PO 7 outside the CHI effort.

First 5 Fresno and LTG have determined that the following questions are key to evaluating PO 7:

• Are parents/caregivers in the First 5 service areas familiar and supportive of the idea that all children should have access to appropriate health care? What may be influencing progress toward establishing this as a community norm?


• Are parents/caregivers more knowledgeable about and actively meeting the health needs of their children?

Are parents/caregivers in the First 5 service areas familiar and supportive of the idea that all children should have access to appropriate health care? What may be influencing progress toward establishing this as a community norm? YES, but the medical system has barriers to health care services Primary evidence for the answer to this question comes from qualitative client interviews that were part of the CHI evaluation (see PO 4 and 5 outcomes, above). Parents agreed that having insurance for their children was extremely important, not only because of the child’s well being, but because it helped financially. One parent stated:

It’s important for my child’s well-being. If something happens, an emergency happens, I want to have a doctor that I’m gonna call and have right away. Instead of, I don’t know, panicking or trying to figure out what to do. And just for regular questions, it’s helpful to ask—‘cause I’m still learning. It’s my first baby. I wanna have a doctor that will give me options and suggestions and not exactly just tell me: “This is the answer. This is the pill, or this is the medicine.” I wanna have other options and suggestions, like how to better take care of the child to prevent it. Or to eliminate that. Or if the medicine is going to ruin his liver in the long run, is there another way to cure, whatever the illness is? There’s many reasons why I think it’s important. But I think the biggest thing that it falls back is financially because if I can’t afford it. I’m only gonna take it in extreme emergency to the doctor. Because otherwise, I’m gonna have to cut other things out, and I wanna have a place to live and food to eat! [CHI Client]

Parents recognized the need to have insurance for all children. However, aside from financial difficulties, they cited barriers within the medical system that prevented or delayed them from obtaining appropriate health care for their children. A major barrier in the medical system was difficulty finding interpreters to communicate with the doctor about health concerns for their children. One parent cited having to use her own child, who is only 5 years old, to get information. This was particularly difficult for parents who spoke a language other than Spanish or English. For example, an indigenous language speaker from Mexico, many of whom are part of the migrant agricultural work force, explained:

Interpreter: She tells me that for her it has been very difficult because not always are there interpreters available to go with her to the clinic to help her. She said that sometimes she sends her child alone to talk to the doctor but she never really knows what the doctor tells him. Sometimes the doctor explains to her child what he needs to do and sometimes he [the child] comes out and tells her what the doctor said. She said that her child speaks Spanish and helps her understand what the doctor said in their native language. [CHI Client]

Insuring all children, particularly those who do not qualify for Medi-Cal or Healthy Families, remains an uncertainty. Although many providers remain hopeful, others expressed a certain level of skepticism when asked about establishing medical care for all children as a community norm. One provider indicated:



Oh well, parents are just like everybody else. I would imagine that most parents would think that children need to have a medical home; a place for their health needs to be followed. Whether they think in terms of: “We need to provide a health plan for that,” I have no idea. And I imagine [among] the middle and upper income people in our County, probably, many of them really strongly feel that this [medical insurance coverage] is something that they have really earned for their kids, and not everybody should have to benefit from it.

There are a number of folks in our communities that really look at the world that way. “You earn it! And if you don’t earn it, you don’t deserve it!” …People are working, and it really doesn’t make any sense to say that they don’t deserve it because they haven’t earned it. I think they have earned it. Everybody has earned it in one way or another. And in terms of children, we can’t afford to have kids growing up unhealthy and with broken eardrums because of difficulty in getting the care they need. [CHI Provider]

Further evidence comes from the CHI Media Campaign’s PAER. They are beginning to see behavior change in parents and families seeking health care for their families. In communities where fear and guilt often held parents back from seeking out health care options for their families in Fresno County, these families are now becoming involved and eager to gain control of their family’s health by applying and enrolling in health insurance.

This behavior change is partly due to the CHI Media Campaign’s preparation and implementation of a multi-level strategy of reaching out to the English, Spanish, and Hmong communities in Fresno County to talk about the importance of children’s health care. The CHI Media Campaign developed tag lines for radio and TV in three different languages (English, Spanish, Hmong). These tag lines were developed from focus group results and individual community member interviews. The tag lines served unique purposes in each community and were sensitive to cultural beliefs regarding health care. Public service announcements and outreach activities were also implemented. The results showed that 191 children ages 0-5 and 706 children ages 6-18 were enrolled in an insurance program, for a total of 897 covered children.

Are parents/caregivers more knowledgeable about and actively meeting the health needs of their children? MOSTLY YES, but some issues remain problematic Evidence for the answer to this question comes from Core Participant Data (CPD) questions, because One-e-App was not able to provide this information for FY 05-06. Several CPD questions asked about health-related topics, such as whether the child had a medical home. To answer this question we have compared parents’ answers to these health-related CPD questions at intake and after participating in a First 5 Fresno-funded program in FY 05-06.

• Did more children have health insurance? NO DIFFERENCE o Out of 640 children with data at two time points:

31 children had gained health insurance at follow-up; and, 18 children had lost health insurance at follow-up.

o This represents no change, because the difference was not statistically significant.


• Did more children have a place for non-ER sick care? YES o Out of 535 children with data at two time points:

42 children had gained a place for non-ER sick care at follow-up; and, 13 children had lost a place for non-ER sick care at follow-up.

o This represents an improvement, because more children gained a place for non-ER sick care than lost one, which was highly statistically significant at the p<.001 level.

• Did more children have medical homes for well-child visits? YES o Out of 635 children with data at two time points:

38 children had gained a medical home at follow-up; and, 16 children had lost a medical home at follow-up.

o This represents an improvement, because more children gained a medical home than lost one, that was statistically significant at the p<.01 level.

• Did more children have well-child visits? NO DIFFERENCE o Out of 515 children with data at two time points:

At intake the average was 2.04 well-child visits in the last year; and, At follow-up the average was 1.98 well-child visits in the last year.

o This represents no change because the difference was not statistically significant.

• Did more children have vaccinations? YES o Out of 318 children with data at two time points:

20 children had increased their vaccination level at follow-up; and, 7 children had decreased their vaccination level at follow-up (did not get

the new ones needed for their age). o This represents an improvement, because more children had increased their

vaccination level than decreased, that was statistically significant at the p<.01 level.

• Did more children have dental insurance? YES o Out of 534 children with data at two time points:

78 children had enrolled in dental insurance at follow-up; and, 27 children had lost dental insurance at follow-up.

o This represents an improvement, because more children enrolled in dental insurance than lost it, that was highly statistically significant at the p<.001 level.

• Had children seen a dentist more recently? NO o Out of 188 children with data at two time points:

9 children had seen a dentist more recently at follow-up than at intake; and,

40 children had seen a dentist less recently at follow-up than at intake. o This represents a setback, because children had seen a dentist less recently

than at intake, that was highly statistically significant at the p<.001 level.



4.7 Summary and Conclusions Six programs address Priority Outcomes pertaining to health, four of which comprise the Children’s Health Initiative (CHI) which received the bulk of funding in 2005-2006 for the Health Priority Area. Two programs lead the CHI, which seeks to provide families with opportunities to enroll uninsured children in existing state-sponsored insurance programs or, if they do not qualify for such insurance, in other local health service programs. Both process and outcome data were gathered, the latter including qualitative perspectives on the strengths and challenges of the CHI.

4.7.1 Process Evaluation It is consistent with the relevant Priority Outcomes that, rather than concentrating on providing direct services, program activities were distributed relatively equally among Direct Services, Community Strengthening Efforts, Provider Capacity Building, and Systems Change Support. Even so, programs provided 3,766 clients – most were Hispanic/Latino children - with about 4,500 service contacts. Community Strengthening Efforts were spread relatively evenly among organizing community events, disseminating information in various ways, public speaking, and media campaigns.

Programs conducted Provider Capacity Building through 266 direct contacts with providers, focusing on issues such as licensing and accreditation issues. System Change Support was provided in a wide range of guises, from seeking funding, to facilitating collaboration and coordination, to advocating for policy and legislative changes.

4.7.2 Outcome Evaluation Outcome evaluation addressed five questions using both quantitative and qualitative data. The data provide affirmative answers to all these questions, but also indicate specific areas of concern, briefly summarized here.

Priority Outcome 4: Reducing Financial Access Barriers to Health Care; and, Priority Outcome 5: Supporting Utilization of Health Systems/Care

1. Has First 5 Fresno reduced financial barriers to health care in order to increase health access for children 0-5? Do more children 0-5 have health insurance coverage in Fresno County as a result of First 5 efforts?

Yes.

2. Have children covered as a result of CHI increased appropriate utilization of preventive and treatment services?

Yes, but interviews with parents indicate that finding the appropriate “medical home” for their children remained problematic.


3. Has First 5 Fresno increased organizations' capacity to enroll children into health coverage programs in the County?

Yes, but the evaluation found that agencies assisting with health care coverage applications found the existing electronic application system cumbersome.

4. Are strategies to increase enrollment into coverage working? Yes, but CHI has had to take care not to let enrollments exceed budget capacity.

5. Has First 5 Fresno improved County capacity to identify uninsured children, enroll them into health coverage, and support utilization and retention/continuity of coverage? Has the particular organizational structure (administration, outreach, etc.) and Fresno CHI components played a unique role in facilitating improvements?

Yes, but while the current method of organizing collaboration has important strengths, some participating organizations found the lack of clearly defined roles and responsibilities could also be an impediment.

Priority Outcome 6: Supporting Children with Behavioral, Developmental, Emotional, Mental Health, and Special Health Needs through Primary Care

1. Has First 5 Fresno improved primary care providers' ability to identify, assess, treat, and refer children with special needs?

Yes.

2. Has First 5 Fresno strengthened the linkages and coordination between primary health care services and developmental/special needs services?

Yes.

Priority Outcome 7: Family Knowledge and Education 1. Are parents/caregivers in the First 5 service areas familiar and supportive of the idea that

all children should have access to appropriate health care? What may be influencing progress toward establishing this as a community norm?

Yes, but the medical system has barriers to health care.

2. Are parents/caregivers more knowledgeable about and actively meeting the health needs of their children?

Mostly yes, but some issues remain problematic

Findings, Strengths, and Challenges from Qualitative Data Finally, the qualitative data gathered on the CHI provide a catalog of findings, strengths, and challenges, as follows.

Findings

• CHI has coordinated the efforts of many different community agencies to identify and enroll children in a health product and connect them to a medical home.

• CHI has successfully implemented a 1-800 telephone line in three languages to provide information and connect families to a local CAA.



• The strategic co-location of CAAs trained to handle at least four health insurance application products (Healthy Kids, Healthy Families, Medi-Cal, and Kaiser) has proven successful.

Strengths

• CHI has successfully combined policy work at local and state levels with community engagement.

• CHI has made insurance application accessible to rural communities. • There have been high levels of community response. • Local agencies in Fresno County express a shared desire to implement a CHI.

Challenges

• There are many more enrollees 6-18 years old than enrollees 0-5 years old. • Communication between organizations became strained as it became evident that

roles and responsibilities were not clearly defined. • Limited or no internal access to information, such as data on enrollments and

actual applications, hindered problem-solving activities and, in some instances, resulted in delayed coverage.

• CAAs experienced difficulty accessing or changing information once submitted into the One-e-App system.

• Once having established medical homes, parents sometimes experienced delays in appointments and fast-paced service settings, both of which created frustration and a sense of being “lost” in the process.



Chapter 5 PRIORITY AREA: CHILDREN WITH BEHAVIORAL, DEVELOPMENTAL,

EMOTIONAL, MENTAL HEALTH, AND SPECIAL HEALTH NEEDS

5.1 Introduction

5.1.1 Goals and Rationale of Priority Area Children with special needs can have serious or chronic health conditions as well as other behavioral, developmental, emotional, and mental health needs. When unaddressed, these health conditions could prevent optimal school readiness by limiting school attendance, ability to concentrate and participate, and even their underlying ability to achieve success. These are the reasons that one of First 5 Fresno’s main foci is early identification and support of children with special needs and their families.

The funded programs in this Priority Area address early assessment, linkages to care, and child and family support for children with special needs. However, First 5 Fresno has made it a priority for all of its intensive service programs and many of its other programs to offer early screenings. First 5 Fresno is working to ensure that children can enter the system of assessment and support through “any open door.” First 5 Fresno believes that early identification of special needs and subsequent linkage to care and support are vital objectives to achieve throughout the County.

In 2005-2006 First 5 Fresno funded 5 programs and disbursed $1,569,644.00 under the Special Needs Priority Area. These programs encompass the following Priority Outcomes:

Priority Area: Special Needs

Priority Outcome 8: Early Identification/Screening Increase the early identification of children 0-5 in all settings with behavioral, developmental, emotional, mental health, and special health needs so that there is ‘no wrong door’ through which early identification can be achieved.

Priority Outcome 9: Assessment and Linkages to Care Increase the number of coordinated, assessment-driven care plans with linkages to appropriate services, which are developed for children with/at risk of developmental delays due to behavioral, developmental, emotional, mental health, and special health needs.

Priority Outcome 10: Responsive Care and Support Increase parent/caregiver capacity to provide responsive care and support for children with behavioral, developmental, emotional, mental health, and special health needs.


5.2 Area Overview First 5 Fresno has funded interventions under the three main Priority Outcomes focusing in this area: Priority Outcomes 8, 9, and 10.

Priority Outcome 8: Early Identification and Screening. This Priority Outcome is designed to increase the early identification of children 0-5 in all settings with behavioral, developmental, emotional, mental health, and special health needs so that there is “no wrong door” through which early identification can be achieved. As described in First 5 Fresno’s Strategic Plan, “under outcome 8, First 5 Fresno strives toward the goal of County wide early and continuous developmental screening for all children 0-5 in order to assure children are on track with their development and to address needs when appropriate.”

A number of other programs funded by First 5, primarily those funded under Priority Outcomes 1, 2, and 3, implemented interventions also supporting this goal. Likewise, the Assessment Center for Children Initiative (ACC), discussed below under section 5.2.2 was part of the support for this Priority Outcome.

Priority Outcome 9: Assessment and Linkages to Care is the primary outcome under which First 5 Fresno funded the Assessment Center for Children Initiative. The goal of this outcome is to increase the number of coordinated, assessment-driven care plans with linkages to appropriate services, which are developed for children with or at risk of developmental delays due to behavioral, developmental, emotional, mental health, and special health needs.

Complementary to Priority Outcomes 8 and 9, Priority Outcome 10 focuses on Responsive Care and Support. Priority Outcome 10 is designed to increase parent/caregiver capacity to provide responsive care and support for children with behavioral, developmental, emotional, mental health, and special health needs. In other words, programs funded under Priority Outcome 10 support parents and/or caregivers of children with special needs to be able to meet the needs of their children.

5.2.1 Program Listing and Expenditures Table 5.1: Special Needs Priority Area Program Listing and Expenditures

ACC Initiative Contract Number Program Name

Priority Outcome


2005CP6018 Assessment Center for Children PO 8 & 9 $564,389.00 2005CP6017 Children's Center - Leverage PO 8 & 9 $466,818.00

Special Needs Initiative Contract Number Program Name

Priority Outcome


2005CP6023 Family Resource Partnership PO 10 $89,885.00 2005CP6020 Parent Support Program PO 10 $31,062.00 2005CP6021 Special Needs Project PO 10 $417,490.00

5.2.2 Assessment Center for Children (ACC) The Assessment Center for Children has been central to efforts under the Special Needs Priority Area, funded by First 5 Fresno since August 2004. It is the result of significant community



efforts to address special needs of children in Fresno County. The goal of the ACC is to serve as a single point of entry for all children 0-5 needing comprehensive behavioral and developmental assessments.

A First 5 Fresno needs assessment conducted in early 2002 revealed a fragmented system and determined that many children who could benefit from early intervention were being overlooked. Parents of high-risk children participating in a focus group discussed common frustrations about the need for multiple assessments at several agencies in different locations, the lack of professional agreement on treatment approaches, and difficulties in locating and accessing services for their children.

Determined to improve on the situation, a partnership among First 5 Fresno, the Fresno County Department of Community Health, and public and private stakeholders implemented the SMART Model of Care, with the assistance of the Children’s Research Triangle in Chicago. The model is a linked system of care anchored by five integrated core functions: Screening, decision-Making, Assessment, Referral, and Treatment (SMART). The SMART Model of Care identifies children 0-5 years of age who are at risk for medical, mental health, emotional, developmental, or learning problems and moves them into a system of care that connects them to services.

The SMART Model of Care became a reality in Fresno with the opening of the Children’s Center (now known as the Assessment Center for Children, or the ACC). The ACC has multidisciplinary staffing that includes physicians, psychologists, occupational therapists, physical therapists, speech and language therapists, infant mental health specialists, and early childhood and developmental specialists. A key feature of the ACC is the co-location and coordination of services by several public and private agencies. The agencies include: Fresno Community Health Department; Central Valley Regional Center (CVRC); Maternal, Child & Adolescent Health (MCAH); Department of Children and Family Services (DCFS); Exceptional Parent’s Unlimited (EPU); Fresno Unified School District (FUSD); and, Fresno County Human Services System/Department of Employment and Temporary Assistance (E&TA). This co-location allows existing assessment resources with multi-agency teams to assess children, minimizing duplication and fragmentation of efforts to provide a comprehensive treatment plan based on the needs of the child.

First 5 Fresno allocated $4 million dollars, over a three-year period (2004 to 2007), to implement comprehensive and coordinated services for children with special needs. Community Partners committed $5,100,000 bringing the total to over $9 million dollars in resources for this cause.9

This initiative addresses primarily Priority Outcomes 8 and 9. Priority Outcome 8 focused on early identification and screening in all settings with behavioral, developmental, emotional, mental health, and special health needs so that there is “no wrong door” through which early identification can be achieved. The goal of Priority Outcome 9 is to increase the number of

9 Concept Paper for Children’s Center - SMART Model of Care, April 26, 2004


coordinated, assessment-driven care plans with linkages to appropriate services, which are developed for children with, or at risk of, developmental delays due to behavioral, developmental, emotional, mental health, and special health needs.

5.3 Program Descriptions

5.3.1 Priority Outcome 8: Early Identification/Screening Although First 5 Fresno did not fund any programs specifically to address Priority Outcome 8, early identification and screening are a major priority for First 5 Fresno. Most intensive service programs, including school readiness and home visitation programs, provided regular screening services for children and families. These efforts will be evaluated along with those of programs funded specifically under Priority Outcomes 9 and 10.

5.3.2 Priority Outcome 9: Assessment and Linkages to Care One agency is the sole program under Priority Outcome 9, which focuses on assessing children with special needs and connecting the children to needed resources. The Assessment Center for Children (ACC) provides centralized assessments, referrals, and resources to children and families with special needs.

One main purpose of the ACC is to collaborate with organizations in Fresno to ensure that children receive the care they need. By strengthening communication between and among organizations, the ACC acts as a resource center for children with special needs. The ACC program collaborates with other service provision organizations in three ways: through its multi-agency team in the assessment process; through its referrals to community organizations as a result of assessing a family’s special needs; and, through direct referrals from its newest service, the One Call Line, a referral hotline service for Fresno County. The One Call Line provides a comprehensive approach to referrals for everyone in Fresno County, including parents, physicians, and public health providers. Another key aspect of the referral process at the ACC is its use of the Children’s Service Coordinator (CSC), who is the initial point of contact for families going through assessments at the center. The CSC continues to individually guide families through the assessment, referral, and follow-up process to ensure a continuum of care.

5.3.3 Priority Outcome 10: Responsive Care and Support Four programs are funded under Priority Outcome 10, which is designed to increase support to parents and caregivers of children with special needs. These four programs include: Family Resource Partnership Project; Special Needs Project; Fresno Area Down Syndrome Society; and, Parent/Caregiver Support Partnership. Fresno Area Down Syndrome Society was subcontracted for reporting purposes through Exceptional Parents Unlimited (EPU), the umbrella organization for ACC.

Key methods that these programs utilize to provide support to parents include workshops, support groups, and resource and service coordination. The topics of workshops and training sessions were diverse. The Family Resource Partnership Project provided comprehensive support to parents of children with special needs through workshops, one-on-one mentoring and support, guidance and resource referrals, service coordination support, collaboration with other agencies



in the service coordination process, parent support groups, and advocacy support to children and their parents in the preparation and maintenance of Individual Education Programs (IEPs). The Parent Support Partnership provided similar services to parents but coordinated their efforts through the Family Resource Specialist. This person acted as a single point of contact and support to parents of children with special needs. The FRS provided support through telephone calls, home visitation, parent support groups, and coordinating efforts with appropriate agencies in Fresno County.

All of the programs in Priority Outcome 10 developed additional services for parents of children with special needs, above their contracted services. One notable example was the Family Resource Partnership Project which established a free resource library for parents to find information and articles on special needs and disabilities. This gave parents a resource to learn more about specific disabilities their children may be facing. Another ancillary service was the support that collaborating agencies provided to parents graduating from the parent education workshops. Members of agencies voluntarily came to support these parents in the education program, promoting cohesiveness and continued partnership between families and providers.

Key components of all of the programs under the Special Needs Priority Area, including Priority Outcome 10, are resources, referrals, and collaboration. By reaching beyond the programs themselves, the organizations under Priority Outcome 10 arranged support from other community organizations for their clients, ensuring that the organizations themselves developed and maintained a strong community network.


5.4.1 Program Location Map Figure 5.1 shows the location of all Special Needs programs throughout Fresno County funded in this Priority Area for FY 05-06.

5.4.2 Program Service Area Map Figure 5.2 shows program service areas, defined by program report of the Zip Codes that they serve, for all Special Needs programs funded in this Priority Area for FY 05-06.

5.4.3 CPD Family Location Map Figure 5.3 shows the home locations for families who were receiving intensive Special Needs services in FY 05-06 throughout Fresno County. There were 173 families who received intensive special needs services in Fresno County. Of these 173 families, 119 families are represented on the map, and 54 families are not represented because of missing or incorrect addresses. There are several potential reasons for missing address data. For instance, clients may have chosen not to provide address information, and/or providers did not collect address information. In other cases, P.O. Box addresses were provided, and because those addresses do not include an actual street address, they cannot be mapped geographically. Finally, a few addresses did not match the zip code that they were listed with, and these discrepancies could not be resolved.



Figure 5.1: Location of the Special Needs Priority Area Programs in FY 05-06



Figure 5.2: Zip Codes Served by Special Needs Priority Area Programs in FY 05-06


Figure 5.3: Home Locations of Intensively-Served Families in Special Needs Priority Area Programs in FY 05-06: Fresno County



Figure 5.4: Home Locations of Intensively-Served Families in Special Needs Priority Area Programs in FY 05-06: Fresno, Clovis, and Sanger


5.5 Process Evaluation This section presents process data for programs in the Special Needs Priority Area, collected through State Aggregate Data (StAD) forms (collecting separate data on Direct Services, Provider Capacity Building, and Systems Change Support) and Core Participant Data (CPD) service forms. Because these data are reported to the State First 5 Commission separately, they will be presented with little interpretation.

There were a total of five programs dealing with Special Needs in this Priority Area. As Table 5.2 shows, most were concerned with providing direct services. In interpreting the following data, it is important to remember that each program may have submitted more than one State Aggregate Data (StAD) form, depending on their program activities. For example, the same program could have submitted one Direct Services form AND one Infrastructure form. Table 5.2: Special Needs Priority Area, State Aggregate Data Form Summary


Programs Turning in

Form* Direct Services 4 Infrastructure Improvement 1 Provider Capacity Building 1 Systems Change Support 2 * A program can turn in multiple forms.

The next five tables summarize statistics from the four programs completing Direct Services StAD forms. Direct Service and Core Participant data in Table 5.3 shows that First 5 Fresno Special Needs programs providing Direct Services to clients in FY 05-06 served 1,471 clients and provided almost 10,000 service contacts to clients, most of which were to parents/guardians of children 0-5. One interesting note is that in FY 04-05 the majority of contacts were to children. In FY 05-06 the majority of contacts were to parents. This shift may be due to a better understanding of reporting definitions on the part of the programs. Table 5.3: Direct Services Unduplicated Counts and Service Contacts


Service Contacts

Intensively-served Children 155 1,513Directly-served Children 308 811Indirect service to Children 3,702Parents/Guardians 984 3,863Other 24 40Total 1,471 9,929

In Table 5.4, service contacts are categorized by several client demographic factors. The majority of service contacts for parents were to Hispanic/Latino parents (50.8%), parents who primarily spoke English (70.3%), and parents of children who were between the ages of 3 and 5 years old. One note about the table is that, as with FY 04-05, although this section reports on programs in the Special Needs Priority Area, the percentage of service contacts to Special Needs children and parents in Table 5.4 is not 100% because the definition of Special Needs for the Direct Services StAD form is narrower than the definition for the Priority Area.



Table 5.4: Direct Services Service Contacts by Client Demographic Children 0-5 Parents/Guardians


Contacts %Service


American Native 3 0.4 47 1.2Asian 19 2.3 51 1.3Black 42 5.2 227 5.9Latino 509 62.8 1,946 50.8Multiracial 19 2.3 292 7.6Other 26 3.2 47 1.2Pacific Islander 4 0.5 18 0.5Unknown 9 1.1 127 3.3White 180 22.2 1,075 28.1Total 811 100.0 3,830 100.0

# of Service Contacts by LANGUAGE English 512 63.1 2,691 70.3Hmong 13 1.6 38 1.0Other 30 3.7 113 3.0Spanish 248 30.6 836 21.8Unknown 8 1.0 152 4.0Total 811 100.0 3,830 100.0

# of Service Contacts by SPECIAL NEEDS STATUS OF CHILD Served Directly Special Needs 544 67.1Non-Special Needs 267 32.9Total 811 100.0Served Indirectly through Parent/Guardian Special Needs 1,467 38.0Non-Special Needs 2,396 62.0Total 3,863 100.0

# of Service Contacts by AGE OF CHILD Served Directly Children 0-3 419 51.7Children 3-5 387 47.7Age Unknown 5 0.6Total 811 100.0Served Indirectly through Parent/Guardian Children 0-3 1,493 38.6Children 3-5 2,234 57.8Age Unknown 136 3.5Total 3,863 100.0

Table 5.5 shows that the most frequently used modalities for Direct Services were Case Management and Class/Workshop, which 2 of the 5 programs used to provide almost 3,000 of the roughly 3,800 total service contacts to parents. Interestingly, In-Person Consult/Service accounts for the majority of service contact to children.


Table 5.5: Direct Services Modality Children 0-5 Parents/Guardians

Modality

Programs Using

Modality Service

Contacts %Service

Contacts % Case management 2 125 15.4 1,423 37.2 Class/workshop 2 144 17.8 1,570 41.0 Distribution of materials 1 0 0.0 83 2.2 Home visit 1 25 3.1 20 0.5 In-person consult/service 2 479 59.1 216 5.6 Phone consultation 1 0 0.0 317 8.3 Public/community event 1 10 1.2 10 0.3 Support group session 1 28 3.5 191 5.0 Total 811 100.0 3,830 100.0

Only one program in the Special Needs Priority Area submitted an Infrastructure Investment form. Table 5.6 shows the program’s report of Infrastructure Investment fund use. Table 5.6: Infrastructure Investment Activity

Activity


Activity Purchasing: Van(s) 1 Purchasing: Computers and office equipment 1

The next two tables summarize statistics from the one program submitting a Provider Capacity Building StAD form. Table 5.7 shows that the First 5 Fresno Special Needs program providing Capacity Building services in FY 05-06 provided 3 service contacts. Again, it is important to note that the figures in the following tables represent service contacts and not unduplicated counts of participants. Table 5.7: Provider Capacity Building Service Contacts by Type of Client Served


Contacts %Other 3 100.0Total 3 100.0

Table 5.8 shows the Provider Capacity Building training topics reported by the one program submitting the form (programs could report more than one). Table 5.8: Provider Capacity Building Activity

Training Topic

Programs Covering

Topic Serving disabilities and special needs 1 Cultural diversity training 1 Practices or information to support school readiness 1 Other 1

Finally, two programs in the Special Needs Priority Area completed Systems Change Support forms for FY 05-06. Table 5.9 shows the systems change activities that these program reported (programs could report more than one).



Table 5.9: Systems Change Support Activity

Activity

Programs Using

Activity Other raising or leveraging of funds 1 Organizing meetings to share information/coordinate/decisions 1 Organizing meetings among providers to coordinate cases 1 Other interagency collaboration 1


5.6.1 Priority Outcome 8: Early Identification/Screening First 5 Fresno’s goal for this Priority Outcome is to: “[i]ncrease the early identification of children (0-5) in all settings with behavioral, developmental, emotional, mental health, and special health needs so that there is ‘no wrong door’ through which early identification can be achieved.” Although First 5 Fresno’s funding of the Assessment Center for Children does fall under this Priority Outcome, First 5 Fresno also is addressing this goal through most of its other direct service programs through the availability of developmental screenings, providing ASQ (Ages and Stages Questionnaire) trainings, and general required use of the ASQ to relevant contracts.

First 5 Fresno and LTG have determined that the key evaluation questions for this PO are:

• Are more children receiving developmental screenings? • Are First 5 efforts resulting in earlier identification of children with special needs? • Are children benefiting as a result of the earlier identifications? • Has the capacity of First 5 funded agencies increased for early identification? Has

First 5 changed the way organizations work together to maximize efficiency and access to early identification and screening services?

• Has First 5 helped to improve the system so that children can be identified through any doorway?

Are more children receiving developmental screenings? YES Because this goal was addressed across most First 5 Fresno programs, primary evidence for the answer to this question comes from several sources: program reports of the number of Ages and Stages Questionnaires administered; program reports of developmental screenings in PAERs; and, program-specific data from the Assessment Center for Children.

• First 5 Fresno programs performed a total of 1,342 developmental screenings in FY 05-06: o School Readiness programs performed 850 screenings. o All other programs performed 492 screenings.

In addition, a question from the Core Participant Data (“Did your child’s doctor, other health care provider, preschool teacher, childcare provider, or other professional ever tell you that they were doing a developmental screening to check how your child is developing and growing?”)


provided evidence that more children are being screened.

• Of the 524 parents with data at two time points (intake and at least one follow-up): o 153 of the 329 parents (46.5%) who said that their child had not had developmental

screening at intake reported that their child had had a screening at follow-up. o This represents a highly statistically significant improvement at the p<.001 level.

Are First 5 efforts resulting in earlier identification of children with special needs? TOO EARLY TO TELL Evidence for the answer to this question will come from a Core Participant Data (CPD) question: “[i]f you were ever told that your child was developmentally delayed or has a disability or special need, how old was your child when you first learned about this?” This is a new question that was added in FY 04-05. Because of this, data are only available for the last quarter of FY 04-05, and all of FY 05-06. Because there is normal variation in child assessments and ages throughout a year, LTG feels that this question should only be answered by comparing yearly averages of child age at first identification. Therefore, the first reasonable assessment of this question must wait until the FY 06-07 report.

Are children benefiting as a result of the earlier identifications? TOO EARLY TO TELL It is difficult to answer this question at this point because currently there are insufficient data to determine whether children are being identified earlier, nor are there sufficient data on child outcomes that are directly related to early identification. This question will be one of the foci for later qualitative work with families and their perceptions of benefits for their child when First 5 Fresno’s efforts have had more time to bear fruit.

LTG does expect, however, that the coordination of services through agencies such as the ACC will help providers and service agencies collaborate in diagnosing, assessing, and serving children and their families. It would seem likely that children are benefiting from this approach due to improvements in early diagnosis and service integration.

Has the capacity of First 5 funded agencies increased for early identification? Has First 5 changed the way organizations work together to maximize efficiency and access to early identification and screening services? YES and YES Evidence for the answers to these questions comes from several PAERs. Most of the programs increased their capacity by introducing the use of the Ages and Stages Questionnaire (ASQ), a First 5 Fresno requirement. This First 5 Fresno requirement also increased the number of programs performing screenings.

• Did programs’ capacity increase? YES o The Addams Elementary School Readiness Program PAER states that they offered

training to teachers to recognize children’s developmental stages. In addition, home visits included the use of the ASQ to screen for developmental issues. In the program’s K-Camp, the staff conducted ASQ screenings as well as combined it with observations from the K-Camp teachers.



o The Burroughs Elementary School Readiness Program’s PAER states that they used the ASQ screening tool in home visits with parents and children as well as distributing the ASQ forms to parents for them to assess developmental needs of their child. The screening is done twice a year for children between the ages 3–5 years and three times a year for children between the ages of 4 months and 3 years. 41 unduplicated children were screened in the preschool sessions in 05-06, 42 unduplicated children were screened through the Hmong case manager’s home visits, and 24 unduplicated children were screened through the Spanish case manager’s home visits.

o The Del Rey School Readiness Project’s PAER states that they screened for developmental issues. One case was through a home visitation where both the parent and home visitor were concerned with the child’s speech development. The child was referred and is receiving services for dental health, mental health, clothing, speech, and language.

o The FIRM PAER states that FIRM and the FIRM Slavic Kids in Focus program administered developmental screenings. Both programs paid particular attention to overcoming cultural and linguistic barriers.

o The Kings Canyon Unified School District Family Connections PAER states that they conducted developmental screenings for 80 unduplicated children. The ASQ was used in these screenings by home visitors and parents. Home visitation has provided early identification and intervention to children with developmental issues. For example, one child had a speech impediment and the parent expressed her concern to the home visitor. As a result, the child was referred to the speech therapist in the local school district, where the child’s older sibling was already attending school. The child was scheduled for testing and therapy.

• Did organizations change the way they worked together to maximize efficiency and access to screenings? YES o The Assessment Center for Children’s PAER states that they worked with other

County and community agencies to expedite the identification and assessment process for families. Some of these agencies include: Exceptional Parents Unlimited (EPU); Central Valley Regional Center (CVRC); First 5 Fresno County; Fresno County Departments of Children and Family Services – Behavioral Health Services (DCFS – BHS); and, Fresno Unified School District (FUSD).

o The Child Health Care Linkages Program PAER states that they assisted with the Info Line to assist providers with site visits. The goal for this fiscal year was 75 site visits but the final number of visits was actually considerably higher: 244 visits. Visits were to providers such as the YMCA Child Development Center, the Learning Center, Northwest Learning Center, and others. Services provided at the site visits included technical assistance.

o The Family Connections West Fresno PAER states that they have reached out to other agencies with success, and they have been helping families by offering home visitation services in the primary language of the family, which has mostly been in Spanish and Hmong. The project is in the process of establishing itself in the community and working with families to provide both fundamental early childhood programs, as well as connecting families with other services and agencies that provide ancillary services.


Has First 5 helped to improve the system so that children can be identified through any doorway? YES, but there are several serious challenges to implementing the “no wrong door” policy Primary evidence for the answer to this question comes from qualitative interviews and focus groups (see table 5.10). Four persons in major staff positions at the ACC were interviewed, as well as five ACC partner organization staff members, and five clients (two were Latino, one African American, and two Caucasian). Table 5.10: Qualitative Data Collection Activities for PO 8, 9 and 10

Assessment Center for Children/Exceptional Parents Unlimited Qualitative Interviews & Focus Groups



ACC Staff Interviews 4 4 Co-located Partner Interviews 5 5 Client Interviews 5 5 Total 14

While there are more “open doors,” the goal of achieving “no wrong door” accessibility is still a work in progress. The “in all settings” is limited to the ACC in this evaluation report, as specified by the First 5 Fresno staff. However, through other investigations such as program site visits and evaluations of the other major initiatives, there is some information about how early identification is working throughout the County beyond the ACC efforts.

One limitation to the “no wrong door” policy was that initially, early screening was anticipated to be countywide through all providers, but this has not materialized. As one ACC staffer noted:

In talking about the continuum of care, we really need the functions that are not the ACC [responsibility] to be done. Such as the “S” [screening] part of SMART [model of care] …If screening could be done throughout the County as it was envisioned, and I think they are working on [it], …then a lot more kids could be identified and not just relying on parents to know who we are and call in [on the One Call Line]…We’re in charge of doing the assessment, referral, and treatment. And so, if we have the screening and decision making out in the community throughout, and I know First 5 is requiring all of our funded sites to do this screening, so that’s good. But I think we need to… outreach to the different communities in Fresno [countywide]… But that’s not something we can do here. [ACC Provider]

Another ACC staffer, on their responsibilities for early identification or screening, stated it even more bluntly:

I think that the earlier identification is not a responsibility of the Assessment Center. It’s in the SMART model but I don’t think that we have full responsibility for that.” [ACC Provider]

One constraint to the “no wrong door” policy for early identification is that the referral from another agency must be made by a physician. This limits agencies without physicians, for example, school programs or community-based organizations. One School Readiness (SR) provider shared her experience:



I did refer, or tried to refer a family to the assessment center and I was told that I needed to have a doctor’s referral. When I went back and talked to the family, because of their insurance, they have a certain doctor, [and] he would not give the referral. It was during the winter; they were gonna wait until January. At that point in time, they could switch doctors. In the meantime, they have dropped out of our program. And we haven’t been able to follow-up with them. They aren’t returning any of our phone calls.10

Another SR provider summarized her program’s experience with referring children to the ACC as follows: “It’s been real difficult to move our way through that system.” Other SR providers stated that the difficulty is exacerbated by parents’ lack of experience dealing with the system, and their lack of awareness about the need to advocate on behalf of their children.11

A provider that refers children and families to the ACC noted that there are tacit eligibility restrictions for child assessment due to the ACC requirement that parents must commit considerable time to the assessment process before intake:

When the Assessment Center first came about, it was frustrating for us…and at first we had a hard time getting kids in there. They were being very, very selective and in their defense, we didn’t realize what it was that they were looking for, what was an appropriate referral. And so then we refer kids and nobody would get back to us…And sitting down with [ACC] and saying OK what kind of kids are you looking for?...And they told us right off the bat, ‘Unless parents are willing to make a commitment of three visits, each visit could be up to 3 hours, then we’re not going to accept the referral because they’re not going to complete. It’s going to be a waste of both of our time.’ And that helped us so that we could prepare parents:…‘This is the commitment, you need to be willing to do this,’ and parents who weren’t, then we got creative, we went out and looked for other resources to refer these kids to.” [ACC Provider]

Another First 5 Fresno funded activity of the ACC is the One Call Line. The One Call Line is essentially the initial point of contact with the ACC for community members, including parents, who call because of a referral or with questions related to special needs. In FY 05-06, the One Call Line fielded 344 calls from parents, agencies, and physicians and made approximately 312 referrals. There were both a wide range of calls and a wide range of results for clients. For example, not every call required an ACC assessment:

The one-call center can sometimes help parents even if their child doesn’t need to come here for an assessment. Sometimes calls come in and it may be that they just need a little information about other services in the community…so the folks in the one-call center sometimes help families in that way. [ACC Provider]

The following is a generalized description of a completed assessment from the time a parent calls the One Call Line to the final recommendations, combining the words of various providers, both

10 School Readiness Focus Group Participant 11 School Readiness Focus Group and Interviews with ECE providers


within the ACC and its partner providers:

There is a one-call number that various people in the community have, so pediatricians might have [it], a social worker might have [it], there may be a brochure that a parent comes across from somewhere…When they [call], the call center gets information and from that information, the child is assigned to a Children’s Services Coordinator who then follows up to obtain information to see if this is in fact a child that would benefit from services here. Or if there are referrals that can be made into the community … So let’s say it looks like the child needs to come here for an assessment. So once the Children’s Services Coordinator [CSC] makes contact with the families there are measurements given, the ASQs [Ages and Stages Questionnaire], the PSI [Parent Stress Index] the CBCL [Child Behavior Checklist] then the information comes into a triage where we review it and we have the initial interview with the CSC and review the information from the measurements and determine who will be on the team and which assessments it seems appropriate to give. [ACC Provider]

What I think the most successful piece of that that I’ve seen is we have a once a week “staffing” and a staffing is, once everybody has seen that child, the CSC requests a staffing and on that day, that’s the only time and place that every clinician is sitting in the same room at the same time…We’ve staffed with one child in a one hour session to maybe four…And you’ve got the developmental pediatrician, you’ve got CVRC [Central Valley Regional Center], you’ve got the entire Fresno Unified Preschool Team, all sitting at one table. You’re not going to ever get that as an individual parent…” [ACC Provider]

And then we sit down with the family after we’ve put in a report, we enter[it] into a data system, and we answer questions. [When] the parents [came to] the initial in-take with the CSC, they [had] a set of questions they want answered, and so we write our reports to the parents answering those questions...It’s important that you don’t just nod to parents when they have those questions because this is what really gives them anxiety, and then you can’t really provide…for your child if you’re anxious. [ACC Provider]

Once this assessment process is completed there is what is termed: “the warm handoff.” This is the referral process to another agency that can work with the family long-term and take responsibility for care, although some of the clinicians at the ACC continue care of the child there:

I think it depends on the situation. We have maybe I could say, parallel courses: one is to do a warm hand-off to other agencies or other treatments, services that could best fit the child’s needs that maybe are not available here. I do have some children that I’m doing ongoing treatment with…so we do both actually. [ACC Provider]

5.6.2 Priority Outcome 9: Assessment and Linkages to Care The goal of this PO is to: “[i]ncrease the number of coordinated, assessment-driven care plans with linkages to appropriate services, which are developed for children with, or at risk of, developmental delays due to behavioral, developmental, emotional, mental health, and special



health needs.”

First 5 Fresno and LTG have determined that the key evaluation questions for this PO are:

• Are more children being assessed and linked with care? Are more children with less severe/intensive needs being assessed?

• Are children benefiting as a result of the earlier identifications, assessments, and coordinated linkages to services?

• Has the ACC impacted the experiences for clients accessing relevant screening, assessment, and referral services?

• Are children being connected to needed services? • Has First 5 improved how organizations work together to produce an efficient,

coordinated approach to comprehensive assessments and care planning that enables partners to fulfill service mandates?

• Has First 5 streamlined the assessment process by minimizing the number of separate client service encounters and speeding the completion of comprehensive assessment, care planning, and follow-up?

Are more children being assessed and linked with care? Are more children with less severe/intensive needs being assessed? YES and TOO EARLY TO TELL Evidence for the answer to this question comes from project-specific data from the Assessment Center for Children (ACC).

• Are more children being assessed and linked with care? YES o A total of 214 children were assessed or were in the assessment process by the end of

FY 05-06. o Of those 214, 118 children had received a Plan of Care or a Referral (data does not

differentiate between POCs and Referrals) in an average of 4.8 visits over an average of 167 days.

o An additional 345 children were served through the Call Line o The program also served 97 parents directly through 485 service contacts.

• Are more children with less severe/intensive needs being assessed? TOO EARLY TO TELL o Because this is the first year for which diagnosis data are available, it is not possible

to tell if more children with less severe/intensive needs are being assessed. Table 5.11 shows the diagnoses of the 19 children on whom the ACC reported diagnoses. Table 5.11: ACC Diagnoses for Assessed Children

Diagnosis Number of

Children Emotional Disturbance/Behavior 6Mental Retardation 2None 2Sensory Processing 1Speech/Language Impairment 8Total 19


Are children benefiting as a result of the earlier identifications, assessments, and coordinated linkages to services? TOO EARLY TO TELL Again, it is difficult to answer this question at this point because insufficient data have been reported to determine whether children are being identified, assessed, and linked to services earlier. This question will be one of the foci for later qualitative work with families and their perceptions of benefits for their child when First 5 Fresno’s efforts have had more time to bear fruit.

Has the ACC impacted the experiences for clients accessing relevant screening, assessment, and referral services? YES, but not for all clients Primary evidence for the answer to this question comes from client satisfaction interviews conducted by the ACC. The ACC reported client satisfaction data on 39 clients for FY 05-06 (see Table 5.12). These data indicate that parents have a high degree of satisfaction with their ACC experiences. Table 5.12: ACC Client Satisfaction Data

Client Response Question Yes NoDid you have any problems getting an appointment with us? 3 35

Did you learn things to help you take better care of your child or to help him/her grow and develop? 36 2

Do you feel that you were listened to and your concerns addressed? 37 1

Did you receive a Plan of Care and written report at the time of your last assessment appointment? 32 7

Are you happy with the service you received? 37 1

Would you recommend us to a friend in need of assessment services? 36 3

Other evidence for the answer to this question comes from qualitative interviews (see table 5.10). Parents’ experiences varied from enthusiastic to more problematic, depending on the child’s problem, referral process, and the parent’s availability to bring the child to the ACC.

A very satisfied parent expressed her appreciation:

Client: [The ACC staffer] took care of everything and she would tell me, ‘There is an appointment coming up on such date and time,’ [and] everything went well. I am very grateful for their help.

Interviewer: How satisfied are you with all the services you received?

Client: 100% satisfied, with everything…I learned during the assessments …how to play better with her. And I also learned that I am a good mom. [Client cries…] Because sometimes one feels guilty, like ‘Why did my child get this? What am I not doing right?’ [ACC Client]



Another parent, who is deaf, found difficulties in obtaining services for her son who is not deaf or hard of hearing, but having other problems:

I had an appointment with EPU and I went and I said I need an interpreter and they said, ‘Well, we don’t have one,’ and I said, ‘Well, are there any adults here that know sign?’ I don’t want to deal with that. I want my son to be able to learn sign language first and then learn to talk. And some of the other children there were not equivalent in disability. There’s Down’s Syndrome, the other children didn’t fit my son’s capability. My son learns very quickly and when they sat and talked to him, he started signing and they didn’t understand him. They couldn’t sign back to him… EPU didn’t provide interpreters; none of the staff know sign language, so I really didn’t want to be involved with an agency like that. [ACC Client]

Client experiences suggest that there may be differential capacities of special needs services available at ACC. While clients with speech disabilities have many options, others with mental health issues or hearing issues, have more limited options.

Are children being connected to needed services? SOME ARE, but many are not The ACC PAER reports that children that are being assessed are being linked with care. This process at the ACC begins with the initial triage and diagnosis by the Children’s Service Coordinator (CSC) and a team of developmental and behavioral pediatric clinicians. CPD data were not collected by the ACC for many children who were assessed and linked with care at the ACC or referred to other providers.

Primary evidence for the answer to this question comes from ACC program-specific data.

• Detailed ACC service data about Plans of Care (POC) or Referrals reports: o 77 children received a Plan of Care and/or a Referral (data from the staff physician

specialist); o 9 children only received Plans of Care (ACC); o 13 children only received Referrals (ACC); and, o 20 children received both a POC and a Referral (ACC).

• Detailed ACC service data about service receipt reports: o 38 children were not receiving services, but had had their Plan of Care for less than 3

months; o 32 children were not receiving services, for various reasons; and, o 23 children were receiving services.

Other evidence for the answer to this question comes from qualitative interviews. Assessment and linkages to care work quite well within the ACC unit of co-located agencies and is unique in the State. According to one ACC staffer:

Interviewer: What do you think is unique about the co-location of agencies for the agencies?

Provider: Definitely, there isn’t anywhere else in town where this happens and I would venture to say that we are pretty unique probably for the State as well.


[We] have traveled around to several counties, as well as some counties have come here to talk to us about it. And none of them, the only one that comes close to that, is Monterey County, but they ...have a multi-disciplinary team but not a multi-agency team. [ACC Provider]

There is a lack of duplication in their process, with everyone sharing the basic information and developing a coordinated approach to the child’s problem. Staff was quite pleased with this. The only issue for some was that because of the summer hiatus, input from the Fresno Unified School District was delayed for those months until the beginning of the Fall term.

Has First 5 improved how organizations work together to produce an efficient, coordinated approach to comprehensive assessments and care planning that enables partners to fulfill service mandates? YES, but referrals are severely limited to physicians The ACC PAER reports that the approach to coordinated services and organizational resources in a “one-stop” shop model for clients in Fresno County is proving to have some benefits for both clients and participating organizations. For example, ACC clients can come to the ACC office for screening, diagnosis, assessment, services, and sometimes referrals typically taking only one or two appointments. However, in non-ACC cases, clients may receive an initial screening in one office and subsequently have to go to several other offices for additional services, delaying diagnoses and treatments. Having one location for clients to come for services and case management is a benefit for parents. In addition, clinicians and organizations that are coordinating their services at the ACC and/or are part of the pediatric assessment team can collaborate in a way that would not be possible if they were in separate office locations.

Primary evidence for the answer to this evaluation question comes from two sources: ACC program-specific data about who referred children to ACC, which demonstrates the extent of linkages; and, qualitative interviews, which provide more detailed information about coordination and assessment efficiency. Table 5.13: ACC Referrers Data

Referrer Number of

ReferralsCCS 1CHCC 1Department of Children and Families 16EPU-ACC 5Hospital/Clinic 4Mental Health Professional 1OT 1Other 3Parent 13Public Health Nurse 5Physician 126School or District 4Total 180

The table above, Table 5.13, lists the sources of referrals of children to the ACC. As is evident in the table, there is a wide variety of referrers, which suggests that there are linkages between



organizations that are leading to referral and assessment of children. Also evident in Table 5.13 is that physicians account for the vast majority of referrals, possibly echoing the difficulties that other agencies who have attempted non-physician referrals previously noted.

Qualitative interviews with ACC staff suggest that while the system of coordination and linkage between agencies is still a work in progress, it is better than the previous situation. With ACC at EPU, the unified, multi-disciplinary approach is very noteworthy. The network of referrals as well as the co-location of multiple agencies at ACC is something that had not existed before.

One provider answered succinctly:

Interviewer: In terms of coordinated efforts, before First 5 started these programs, was something like this happening?

Provider: No, definitely not. [ACC Provider]

Then the provider goes on to describe the previous process without the ACC:

[Prior to the Assessment Center], what we would have to do is, say I have a kid in Fresno, I see developmental delays, I see speech delay, I see challenging behaviors, mom’s an addict, dad’s in prison, say that scenario. I would have to make referrals to Fresno Unified for speech evaluation, I’d have to call the primary doctor to get a referral to see [the medical specialist in behavioral and developmental problems], I would have to get in touch with the school. Maybe the school psychologist will do an assessment. There were a lot of more phone calls to be made to get services for these families. Now if the family meets the [ACC] criteria and they are willing to go through what needs to be done, then they can do it all there. And they provide transportation for rural families that have no transportation, and there’s the Medi-Cal piece too that the [ACC case] worker’s going to help the family apply for food stamps, apply for the Medi-Cal program. But yeah, the Assessment Center really has brought something great to the table. And just like anything else, it’s not for…all kids, just the chosen ones that can, that families can make that commitment. [ACC Provider]

Has First 5 streamlined the assessment process by minimizing the number of separate client service encounters and speeding the completion of comprehensive assessment, care planning, and follow-up? SOMEWHAT, but many barriers remain Evidence for the answer to this question comes from two sources: ACC detailed program-specific data about service provision; and, qualitative interviews with staff and parents.

According to the ACC program data presented in the first answer for this PO, the 118 children who received Plans of Care and/or Referrals received them in an average of 4.8 visits over an average of 167 days. These figures are given context by the qualitative interviews with the ACC staff. Staff reported that they underestimated the time it would take to evaluate a child—both from the clinical side, and the amount of time a child can tolerate being evaluated, particularly one with development or behavioral problems. Here is one staffer’s explanation of the assessment time needed for each agency:

It was thought that this would be a one-day assessment. But we now know, CVRC [Central Valley Regional Center] takes 1 ½ hours, and Fresno Unified takes two


days right up front, they always take two days. You’ve got the mental health clinician that wants to spend a couple of hours and you have a four year old autistic child who is done in a half an hour with all of you. On paper, the one day assessment sounds great because you have the parents coming to one location, meeting with all these people. It’s easier for transportation, it’s easier for parents who have to take off work, [and] you know, we were providing the childcare. So on paper it looked really good, really productive… So what ended up happening was our goal of one assessment day, has turned into multiple assessments over multiple timeframes. [ACC Provider]

In addition, the child can only last for a few hours in an unfamiliar setting. That same staffer explained:

What we found is about 2 ½ hours [is their limit] and that’s a cooperative child, [after] 2 ½ hours you know they’re tired. They need naps, they need food, so then you have to question the quality of your assessment [after they’ve reached their limit]. [ACC Provider]

As the ACC has learned, the time a parent must be able to commit is sizable for working parents: three hours for three days each. This limits eligibility for assessment.

The ACC also was confronted with several unanticipated logistical problems. One such problem was dealing with the confidentiality requirements associated with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This was a barrier to the inter-agency sharing of client diagnoses and treatments that had to be resolved. According to one ACC provider:

There are more issues with technology than we had ever imagined. I mean we knew [about] the HIPAA stuff but we didn’t know how it played out... [sharing information] across the agencies going back and forth. [ACC Provider]

Another logistical problem that led to delays in service was staff turnover. Staffing is not up to capacity because, according to an ACC provider:

What’s happened is that we haven’t been staffed at the level that the agencies have committed to and we’ve had…staff turnover…When we initially planned, we had two physicians and a nurse practitioner. Now we have one physician. [ACC Provider]

Furthermore, providers and parents reported that it is difficult to hire qualified specialists to fill vacancies once they occur because of limitations in the Central Valley labor market for the type of highly trained individuals that they require. One mother said: “In [my son’s] preschool, there was a turnover of four aides, [then] within two weeks [there was a turnover] of seven aides.” She reported that there weren’t enough people to fill the positions for handicapped children. She even has been in touch with her school district’s administrator telling him: “It’s not my problem. This is the law. This is what you have to do.” His reply was: “My hands are tied,” meaning he couldn’t hire appropriately trained people if they did not exist.

Finally, according to interviews, the ACC could use more dedicated space for co-located staff to perform assessments, store test materials, have occupational therapy equipment, and diagnostic toys.



5.6.3 Priority Outcome 10: Responsive care and support The goal for Priority Outcome 10 is to: “[i]ncrease parent/caregiver capacity to provide responsive care and support for children with behavioral, developmental, emotional, mental health, and special health needs.” First 5 Fresno funded three programs in the Special Needs initiative to address this goal.

First 5 Fresno and LTG have determined that the key questions for this PO are:

• Has First 5 improved parents/caregivers' (of children with special needs) understanding of their children’s needs, and ability to provide, advocate for, and access responsive care and services?

• Have care/services benefited children with special needs and their families, including respite, moral/emotional/social support of parents?

Has First 5 improved parents/caregivers' (of children with special needs) understanding of their children’s needs, and ability to provide, advocate for, and access responsive care and services? TOO EARLY TO TELL Qualitative data on this Initiative were not conclusive as the Initiative was just beginning, services were still highly decentralized, and families were difficult to identify for interviews by agencies. Furthermore, the sample that was obtained was too small with inconclusive results. However, we do anticipate that in the coming fiscal year, 2007-08, more conclusive and reliable data will be obtained.

The EPU Parent/Caregiver Support for Children with Special Needs PAER reports that they provide mentoring, support, and service coordination, as well as advocacy support, to parents/caregivers of children 0–5 years who have special needs. In this fiscal year, EPU provided support to 4,753 parents/caregivers. EPU also reached out to 840 parents/caregivers through support group activities.

The Family Resource Partnership Project PAER reports that they worked directly with families in rural areas of Fresno County to connect them with services in Coalinga, San Joaquin, and Firebaugh, as well as in Fresno itself. The Project also established the Resource Library for parents located at the West Hills College Child Development Center – Coalinga Family Literacy Room. Resources are provided to help parents and family members research their children’s disabilities in great detail.

The Bridge to Empowerment PAER reports that they have increased deaf families’ knowledge and skills in nurturing the communication, language, and literacy development of their children through their Language Enrichment Activity Program (LEAP). They also assisted families in understanding basic child development, parenting, and health information that many of them would not ordinarily have access to because of communication and literacy barriers. Several families received information, in their language, about the dangers of tobacco and the availability of smoking cessation programs.

Primary evidence for the answer to this question will come from parents’ answers to questions on the Family Outcomes Survey (FOS), an instrument for assessing attitudes, knowledge, and behavior in families who have children with special needs. Currently, First 5 Fresno has only baseline data from the FOS because FY 05-06 was the first year that First 5 Fresno implemented


its collection. Selected baseline results from these data are presented below.

• 50 parents answered Family Outcome Surveys by choosing answers to each question on a scale from 1 (not confident/just beginning/etc.) to 7 (confident/routine/etc.), with 4 as the exact middle. Their answers indicated that: o Parents feel like they understand a reasonable amount about their child’s special

needs (average score was 4.3); o Parents are not as confident that they know how to help their child behave the way

they like them to (average score was 3.5); o Parents are also not as confident that they know what programs and services are

available (average score was 3.4); and, o Parents are more confident in advocating for their children (average score was 4.8).

Have care/services benefited children with special needs and their families, including respite, moral/emotional/social support of parents? TOO EARLY TO TELL The EPU Parent/Caregiver Support for Children with Special Needs PAER reports that they provided parent education classes on the basics of parenting and other issues, parents of children with special needs may be facing including anger management. A child support program implemented during FY 05-06 provided families with children with special needs an opportunity to go places and participate in activities that families may not have attempted on their own due to the safety issues faced by these families in regards to their children with special needs. The results of both the parent education classes and the child support program were that new connections and supportive friendships developed between parents of children with special needs and between parents and their children.

The Bridge to Empowerment PAER reports that their families and children have benefited from meeting with other families at “fun field trips” and special events. More than 50 people attended The Bridge to Empowerment’s family day at the Hillcrest Tree Farm and Railroad, including parents, children, siblings, and extended family members. Over 100 people attended their Bridge to Empowerment Open House in December, where they learned of community resources, socialized with other deaf families, and enjoyed food and games with their children.

The Family Resource Partnership Project PAER reports that they coordinated opportunities for parents/caregivers to receive parent-to-parent group support. These opportunities included Parent Support Group Meetings, Play Groups, and Parent/Caregiver workshops that met the needs of the parents/caregivers and allowed them to engage with others. Parents/caregivers also had access to enriched childcare support while attending these meetings.

Again, primary evidence for the answer to this question will come from parents’ answers to questions on the Family Outcomes Survey (FOS). Currently, First 5 Fresno has only baseline data from the FOS because FY 05-06 was the first year that First 5 Fresno implemented its collection. Selected baseline results from these data are presented below.



• 50 parents answered Family Outcome Surveys by choosing answers to each question on a scale from 1 (not confident/just beginning/etc.) to 7 (confident/routine/etc.), with 4 as the exact middle. Their answers indicated that: o Parents feel like they usually have someone that they can talk to who will listen

(average score was 4.7); o Parents feel like they have some support (“someone they can rely on for help”)

(average score was 3.8); and, o Parents feel like their families are able to do enjoyable things (average score was

4.2).

5.7 Summary and Conclusions Five programs pertaining primarily to this Priority Area were funded, although the Assessment Center for Children may be considered the most central of these. A variety of quantitative and qualitative data address process and outcomes for programs serving each of the three most relevant Priority Outcomes.

5.7.1 Process Evaluation Among all five programs, activities focused on providing Direct Services, which reached 1,316 unduplicated clients, providing 8,416 service contacts primarily through case management and workshops, and largely to parents and guardians of children 0-5. It is of interest that most of the children were, in fact, between 3 and 5 years old and English was the primary language of just over 70% of the parents receiving Direct Services.

Only one program used funding for Infrastructure Improvement, and only one used funds for Provider Capacity Building, the latter in the shape of training pertaining to serving clients with disabilities and special needs, addressing cultural diversity, and supporting school readiness. Two programs used funds for System Change Activities, including facilitating collaboration and obtaining funds.

5.7.2 Outcome Evaluation Separate but similar key evaluation questions were posed for each of the Priority Outcomes pertaining to the Priority Area addressed in this chapter. The answers the data provide to these are summarized below.

Priority Outcome 8: Early Identification and Screening 1. Are First 5 efforts resulting in earlier identification of children with special needs? More data are required before this question can be answered with confidence.

2. Are children benefiting as a result of the earlier identifications? More data are required before this question can be answered with confidence, although a positive answer seems likely.


3. Has the capacity of First 5 funded agencies increased for early identification? Has First 5 changed the way organizations work together to maximize efficiency and access to early identification and screening services?

The data answer both parts of this question in the affirmative.

4. Has First 5 helped to improve the system so that children can be identified through any doorway?

As described in detail earlier in this chapter, there are several challenges to implementing the “no wrong door” policy. Results so far must be characterized as mixed.

5. Are more children receiving developmental screenings? The data clearly say “yes” to this question.

Priority Outcome 9: Assessment and Linkages to Care 1. Are more children being assessed and linked with care? Are more children with less

severe/intensive needs being assessed? The data say “yes” to the first part of this question, but additional data are needed to be sure more children with less severe or intensive needs also are being assessed.

2. Are children benefiting as a result of the earlier identifications, assessments, and coordinated linkages to services?

Again, this question will be answered only after more data are gathered.

3. Has the ACC impacted the experiences for clients accessing relevant screening, assessment, and referral services?

The data show primarily positive results, although those needing certain kinds of services have found less satisfaction than the majority of parents and children.

4. Are children being connected to needed services? The data present a mixed picture, in which provision of plans of care and referrals is, so far, outstripping receipt of services.

5. Has First 5 improved how organizations work together to produce an efficient, coordinated approach to comprehensive assessments and care planning that enables partners to fulfill service mandates?

Although it appears that there are still obstacles to non-physician referrals, the referral network and co-location of agencies at the ACC represent distinct progress.

6. Has First 5 streamlined the assessment process by minimizing the number of separate client service encounters and speeding the completion of comprehensive assessment, care planning, and follow-up?

The data show movement in the right direction, although unanticipated administrative and procedural issues, staff turnover, and space limitations have proven challenging.

Priority Outcome 10: Responsive Care and Support As of this report, only baseline data pertaining to the key questions regarding this priority Outcome have been collected. Answers will depend on the data from subsequent years.



1. Has First 5 improved parents/caregivers' (of children with special needs) understanding of their children’s needs, and ability to provide, advocate for, and access responsive care and services?

Too soon to tell.

2. Have care/services benefited children with special needs and their families, including respite, moral/emotional/social support of parents?

Too soon to tell.

Findings, Strengths, and Challenges from Qualitative Data Finally, the qualitative data gathered on the ACC provide a catalog of findings, strengths, and challenges, as follows:

Findings

• Providing coordinated and co-located services is an innovative program in Fresno County.

• The One-Call line is a unique and useful resource for County residents and service providers.

Strengths

• The quality of the professional staff of ACC is excellent. • The ACC facilities are well designed and staffed. • Transportation services are provided for rural residents.

Challenges

• Screening is not available throughout the County or in a centralized facility, limiting referrals.

• HIPAA rules require more detailed inter-agency coordination than anticipated. • More time than one day is required to do comprehensive assessments. • Parents must commit to three days of evaluation. • Young children can only tolerate a limited time in a clinic setting. • Referrals are limited to physicians, excluding other sources, such as schools. • More space than anticipated is needed for co-located staff and assessments. • Rural communities are still at a disadvantage for screening and treatment, even with

transportation provided for assessment. • Not all special needs are equally addressed; for example, the deaf and hard of hearing

have comparatively limited options. • Respite services for parents are not well known or used. • Turnover and replacement of specialized staff is a challenge in Fresno County



Chapter 6 COMMUNITY-BASED INITIATIVES

6.1 Community-Based Initiatives Overview Community-Based Initiatives provide community members with the opportunity to submit a grant proposal that may support services for children 0-5 that are not part of specific Priority Outcomes. First 5 Fresno describes this initiative and its requirements as follows:

The Community-Based Initiative (CBI) programs are based on the notion that those living and working in a community have a unique and critical understanding of their community assets and needs and that they have creative ideas for effectively addressing those needs.

Funding support is targeted to maximize a community’s own resources, involving members of the community with untapped potential. Each CBI funding request must address the First 5 Fresno County Strategic Plan. In September 2004, the Fresno County Children and Families Commission adopted the current Strategic Plan,

“Putting Children First.” The Plan outlines an outcomes-based set of desired Strategic Results, Objectives, and Goals that guide the Commission in prioritizing funds for efforts to:

• Create strong families to improve family functioning; • Improve child development so children are ready for school; • Improve children’s health; and, • Improve systems for families so services are integrated, accessible, culturally-

appropriate, and of high quality.

This initiative includes funding supporting General Grants, Capital Grants, Mini-Grants and Event Sponsorships. The following sections will discuss each one of the grant programs in detail.


6.2.1 Program Location Map Figure 6.1 shows the location of all Community-Based Initiative programs throughout Fresno County funded for FY 05-06.

6.2.2 Program Service Area Map Figure 6.2 shows program service areas, defined by program report of the Zip Codes that they serve, for all Community-Based Initiative programs funded for FY 05-06.


Figure 6.1: Location of Community-Based Initiative Programs in FY 05-06



Figure 6.2: Zip Codes Served by Community-Based Initiative Programs in FY 05-06


Figure 6.3: Home Locations of Intensively-Served Families in Community-Based Initiative Programs in FY 05-06: Fresno County



Figure 6.4: Home Locations of Intensively-Served Families in Community-Based Initiative Programs in FY 05-06: Fresno, Clovis, and Sanger


6.2.3 CPD Family Location Map Figure 6.3 shows the home locations for families who were receiving intensive services from Community-Based Initiative programs in FY 05-06 throughout Fresno County. There were 212 families who received early childhood education services in Fresno County. Of these 212 families, 163 families are represented on the map, and 49 families are not represented because of missing or incorrect addresses. There are several potential reasons for missing address data. For instance, clients may have chosen not to provide address information, and/or providers did not collect address information. In other cases, P.O. Box addresses were provided, and because those addresses do not include an actual street address, they cannot be mapped geographically. Finally, a few addresses did not match the zip code that they were listed with, and these discrepancies could not be resolved.


6.3 Process Evaluation Because the Community-Based Initiatives programs are so varied, and are not readily classified into initiatives or thematic areas, we will present process evaluation information (and make a note about outcome evaluations) before describing the programs in General Grants, Capital Grants, and Mini-Grants and Event Sponsorships.

This section presents process data for Community-Based Initiative programs collected through State Aggregate Data (StAD) forms (collecting separate data on Community Strengthening Efforts, Direct Services, Infrastructure, Provider Capacity Building, and Systems Change Support) and Core Participant Data (CPD) service forms. Because these data are reported to the State First 5 Commission separately, they will be presented with little interpretation.

There were a total of 48 Community-Based Initiative programs, not all of which were required to turn in State Aggregate forms. As Table 6.1 shows, the most common modality was providing Direct Services. In interpreting the following data, it is important to remember that each program may have submitted more than one State Aggregate Data form, depending on their program activities. For example, the same program could have submitted one Direct Services form AND one Infrastructure form. Table 6.1: Community-Based Initiatives, State Aggregate Data Form Summary


Programs Submitting

Form* Community Strengthening Efforts 9 Direct Services 19 Infrastructure 4 Provider Capacity Building 11 Systems Change Support 3 * A program can turn in multiple forms.

The next two tables summarize statistics from the 9 programs submitting Community Strengthening StAD forms. Table 6.2 shows that the most frequently used modalities were Community Events and Information Dissemination, although more people were reported reached



through Media Campaigns. As with previous chapters, we note that the audience estimates for Media Campaigns are more difficult to estimate than audience estimates for Community Events. Table 6.2: Community Strengthening Modality


Estimated Size of

Audience Community events, celebrations, fairs 4 55,473 Information dissemination 5 16,479 Media campaigns 3 771,000 Public speaking 1 791 Other community strengthening efforts 1 70

Table 6.3 shows that the most common topic covered by programs (programs could report more than one) was Community Resource Awareness. Table 6.3: Community Strengthening Topics


Tobacco cessation 3 School readiness 2 Children with disabilities and special needs 2 Community resource awareness 7 Safety education and violence prevention 6 Prenatal care 2 Breastfeeding 2 Nutrition 2 Preventive health care for children 3 Positive parenting practices 6 Peer support networks 2

The next five tables summarize statistics from the 19 programs submitting Direct Services StAD forms. Direct Service and Core Participant data in Table 6.4 shows that First 5 Fresno Community-Based Initiative programs providing Direct Services to clients in FY 05-06 served 6,563 clients and provided more than 20,000 service contacts to those clients, more than 8,000 of which were to children aged 0-5 years old. Table 6.4: Direct Services Unduplicated Counts and Service Contacts


Service Contacts

Intensively-served Children 152 1,811Directly-served Children 2,866 6,238Indirect service to Children 3,561Parents/Guardians 3,361 8,710Other 184 431Total 6,563 20,751

In Table 6.5, service contacts are categorized by several client demographic factors. The most common service contacts were with children of Unknown ethnicity (33.3%), Hispanic/Latino parents (65.6%), children whose primary language was Unknown (34.2%), parents who primarily spoke Spanish (49.3%), children served directly or indirectly with Non-Special Needs (96.9% and 97.4%, respectively), and children who were between the ages of 3 and 5 years old


served directly (60.7%). Table 6.5: Direct Services Service Contacts by Client Demographic



Contacts %Service


American Native 0 0.0 2 0.0Asian 193 3.1 305 3.5Black 152 2.4 239 2.7Latino 1,847 29.6 5,713 65.6Multiracial 328 5.3 168 1.9Other 296 4.7 588 6.8Pacific Islander 0 0.0 1 0.0Unknown 2,076 33.3 504 5.8White 1,346 21.6 1,190 13.7Total 6,238 100.0 8,710 100.0

# of Service Contacts by LANGUAGE English 1,640 26.3 2,710 31.1Hmong 128 2.1 220 2.5Other 1,325 21.2 1,053 12.1Spanish 1,012 16.2 4,290 49.3Unknown 2,133 34.2 437 5.0Total 6,238 100.0 8,710 100.0


# of Service Contacts by AGE OF CHILD Served Directly Children 0-3 2,435 39.0Children 3-5 3,785 60.7Age Unknown 18 0.3Total 6,238 100.0Served Indirectly through Parent/Guardian Children 0-3 1,856 44.2Children 3-5 1,730 41.2Age Unknown 616 14.7Total 4,202 100.0

Table 6.6 shows that the most frequently used modality for Direct Services was Class/Workshop, which 14 of the 31 programs used to provide more than 7,300 of the almost 15,000 total contacts.



Table 6.6: Direct Services Service Contacts by Modality Children 0-5 Parents/Guardians

Modality

Programs Using

Modality Service

Contacts %Service

Contacts % Case management 5 1,175 18.8 1,245 14.3 Class/workshop 14 3,608 57.8 3,726 42.8 Distribution of materials 1 122 2.0 121 1.4 Home visit 5 389 6.2 486 5.6 In-person consult/service 4 138 2.2 2,552 29.3 Other 1 124 2.0 172 2.0 Support group session 3 682 10.9 408 4.7 Total 6,238 100.0 8,710 100.0

Four Community-Based Initiative programs submitted Infrastructure Investment forms. Table 6.7 shows that all four programs used the funds for Building New Facilities. Table 6.7: Infrastructure Investment Activity

Activity


Activity Facilities: Building new facilities 4

The next two tables summarize statistics from the 11 programs that submitted Provider Capacity Building StAD forms. Table 6.8 shows that First 5 Fresno Community-Based Initiative programs providing Capacity Building services to providers in FY 05-06 provided almost 3,000 service contacts to providers, more to health care providers than to any other provider category. Again, it is important to note that the figures in the following tables represent service contacts and not unduplicated counts of participants. Table 6.8: Provider Capacity Building Service Contacts by Type of Client Served


Contacts %Family-based ECE providers 298 10.3Center-based ECE providers 709 24.5Kindergarten teachers 34 1.2Health care 1,197 41.3Family support 276 9.5Other 384 13.3Unknown 0 0.0Total 2,898 100.0

Table 6.9 shows that the most common Provider Capacity Building training topic reported (programs could report more than one) was Other Provider Capacity Building Activities. Table 6.9: Provider Capacity Building Training Topics

Training Topic

Programs Covering

Topic Serving disabilities and special needs 3 Cultural diversity training 2 Practices or information to support school readiness 4 Other 8


Three Community-Based Initiative programs submitted Systems Change Support forms for FY 05-06. Table 6.10 shows that the most common Systems Change Support activities (programs could report more than one) were: Organizing Meetings to Share Information, Coordinate, or Make Decisions; and, Other Interagency Collaboration. Table 6.10: Systems Change Support Activity

Activity

Programs Engaging in Activity

Conducting community asset mapping/needs assessment 1 Community planning efforts involving residents 1 Preparing documents to support policy changes 1 Establishing or maintaining registries and databases 1 Organizing meetings to share information/coordinate/decisions 2 Organizing meetings among providers to coordinate cases 1 Other interagency collaboration 2

6.4 Outcome Evaluation Due to the diverse nature of the Community-Based Initiatives, evaluation for these programs remained at the program level. Only Process Evaluation data are available (see previous section).

6.5 General Grants

6.5.1 Overview General Grants are one of the primary funding sources under the Community-Based Initiatives. Following General Grants are Capital Grants and, lastly, Sponsorships and Mini-Grants (see sections 6.6 and 6.7). General Grants are defined by Commission staff as funding opportunities resulting from needs brought forward by community groups that are not part of the ten Priority Outcomes. “The program enables providers and other groups, organizations and agencies to initiate and bring forth innovative, effective services for funding consideration.”12

12 Described in Strategic Plan Report



6.5.2 Program Listing and Expenditures Table 6.11: Community-Based Initiative General Grants Program Listing and Expenditures

General Grants Contract Number Program Name


1006GG5031 0-5 in 30 Minutes (Season 3&4) $79,304.00 2002CP6515 Better Baby Care Coordinator $436.00 1006GG5029 Building Within REACH $25,744.00 01CARE02 C.A.R.E.S. Program $246,951.00 1004GG5012 Cal Safe - Teen Home Visitation /Parenting Project $5,061.00 2004CP6005 Car Seat Program $25,002.00 1005GG5023 Center for Breastfeeding Medicine $46,508.00 1004GG5015 Centralized Eligibility List Program $22,331.00 1005GG5026 Child Abuse Mandated Reporting Training $32,618.00 1005GG5022 Child Care Technical Assistance $268,142.00 014C01 Child Development Counseling Project $35,025.00 2004CP6001 Children Safe at Home $18,795.00 1005GG5024 CYM Learning Center $74,976.00 1005GG5025 Deaf Families Reading Together $40,992.00 1005GG5020 Early Childhood Science Education $0.00 1004GG5019 First Footsteps $108,788.00 1005GG5028 Health Disparities Project $70,441.00 1006GG5035 Healthy Families Project $676.00 1002GG5009 Healthy Steps for Young Children Project $161,294.00 2004CP6003 Home Safe-T-Time Program $31,883.00 2004CP6004 Home Safety Education For Southeast Asian Families $24,029.00 2004CP6013 Injury Prevention Mentors Project $87,295.00 1004GG5014 Literacy Services Aprendo Van $49,911.00 006A01 Malaga Children and Families Project $2,790.00 1004GG5018 Na Vali Daatun - Healthy Children $83,130.00 2002CP6509 Network of Care - Kids $22,000.00 1002GG5008 Palliative Care Services $2,653.00 014A01 Parent Mobile Outreach and Services Project $24,264.00 1004GG5017 Slavic Kids in Focus $108,913.00 2004CP6002 Southeast Asian Child Passenger Safety Program $32,421.00 2004CP6006 TAC - Together for Asthma Control $314,782.00 1006GG5030 Teaching Tidepools $32,137.00 2004CP6009 Water Watcher Program $118,863.00

6.5.3 Program Descriptions Programs funded under the Community-Based Initiative General Grants are diverse in scope and nature. The sole common denominator is efforts to meet the needs of children 0-5 and their families. Many programs offer opportunities for children to have access to hands-on educational activities and resources (e.g., Teaching Tidepools, Early Childhood Science Education, Literacy Services Aprendo Van), while others focus on family and provider education on a variety of topics. For example, the Health Disparities project provides education, outreach, and referrals related to specific health topics, which include HIV, Sudden Infant Death Syndrome (SIDS), and sickle cell anemia.

Another project, Together for Asthma Control, worked with medical providers, as well as


families with a child suffering from asthma. Medical providers received information and technical support to prevent or manage asthma in children 0-5. Meanwhile staff also worked with families via case management and home visits to educate and provide referrals and resources needed to reduce the onset of asthma attacks and help families cope with the illness. Some programs focused their work on parents. One such program is the Center for Breast Feeding Medicine, which helps new mothers to learn how to breast feed, teaching them breast feeding techniques, and providing information and support.

Many projects focused on safety, including: Water Watcher Program; Injury Prevention Mentors; Home-Safe-T-Time; and, Home Safety Education. These programs provide information and resources to families in order to reduce child-related injuries and deaths.

Programs vary in scope but also in targeted communities. Some present opportunities to serve children from distinct language and cultural backgrounds. Examples include: Slavic Kids in Focus, which works with Russian/Ukrainian refugees; Na Vali Daatun, which works with Mixteco indigenous families from Mexico; and, Home Safety Education For Southeast Asian Families, which works with Hmong, Mien, and Lao families.

Overall, General Grants afford community organizations the opportunity to address specific needs relevant to children 0-5 and their families. While not all programs deliver the same services, all of them provide unique opportunities for families, providers, and the community at large to provide education, resources, referrals, and general information to support the overall well being of children 0-5 and their families.

6.6 Capital Grants

6.6.1 Overview Capital Grants provide financial awards to support capital projects benefiting children 0-5.

6.6.2 Program Listing and Expenditures Table 6.12: Community-Based Initiative Capital Grants Program Listing and Expenditures

Capital Grants Contract Number Program Name


2002CP6008 FUSD-Capital Agreement $800,000.00 1005GG5027 KCUSD Orange Cove Even Start Capital Project $128,430.00 1005GG5021 Lincoln Even Start Capital Project $77,580.00

6.6.3 Program Descriptions Only three Capital Grants were awarded during FY 05-06. These grants supported infrastructure for projects in various schools around the County. The Orange Cove Even Start Capital Project made possible the construction of a building to house an Even Start Program in the city of Orange Cove. Originally, Orange Cove Even Start planned to implement a program to strengthen the success of area families through individual and interactive literacy training, parenting education, and adult basic education courses via center- and home-based instruction.



Unfortunately, the program was not implemented due to Even Start budgetary issues by the time the building was completed. Therefore, First 5 Fresno decided to utilize the building to provide Home Visitation related services in the community.

The same situation occurred at Lincoln Even Start. The Capital Grant benefited Sanger, a small rural community, which program staff described as “plagued with some of the lowest parent educational levels in the state and one of the highest rates of poverty.” Lincoln Elementary School was awarded an Even Start grant to address the severely limited rate of literacy for families with children from birth to seven years of age. However, after the building was completed, due to district growth, the classroom originally planned for the Even Start program has now been allocated by the school for a Kindergarten class and other First 5 related activities.

The Fresno Unified School District (FUSD) Capital Agreement grant is part of a multilateral effort to support the construction of 10 new elementary schools in Fresno County, which is tied to “Measure K,” passed by Fresno voters in 2001. First 5 staff members participated in a number of meetings with other stakeholders to address specific goals and fiscal capabilities. The meetings resulted in the development of a partnership referred to as the School Readiness Leveraging Partnership. According to First 5 staff, the School Readiness Leveraging Partnership is a joint venture between Fresno Unified School District and First 5 Fresno and allows both agencies to “leverage each others’ funding and, in turn, draw down matching funds from the State School Facilities Program.”13

The capital grant permitted FUSD to design instructional spaces for First 5 to be incorporated into the primary construction contract, “to provide direct preschool instruction and community resources and outreach, specifically to children 0-5 and their families at each new facility.”14 This leveraging partnership has been in effect for the last three years and Commission staff members anticipate that capital cost committed by First 5 will gradually be reduced. First 5 staff described the proposal for this grant as follows: “the proposed partnership provides First 5 an opportunity to not only leverage funding but to ensure that ‘permanent’ pre-K facilities are available to serve the 0-5 population in each community.”15

6.7 Mini-Grants/Event Sponsorships

6.7.1 Overview Mini-Grants provide smaller amounts of funding to support community-based projects and capacity-building activities not funded through other sources. There are two types of Mini-Grants: those funded directly by the Commission; and, those funded through Central Valley Children Services Network. The latter are called Childcare Mini-Grants and are intended to provide support to childcare providers (both center-based and family childcare providers) with the goal of improving program quality.

13 As stated on proposal narrative in Agenda Item #8; Commission Meeting November 6, 2003. 14 Ibid. 15 Ibid.


Event Sponsorships provide one-time financial support for specific events that address the First 5 Strategic Plan. Events eligible for support are those that provide “direct benefit to the community.” Some examples include health fairs, community days, and neighborhood events.

6.7.2 Program Listing and Expenditures Table 6.13: Community-Based Initiative Mini-Grants & Event Sponsorships Program Listing and Expenditures

Commission Mini-Grants & Sponsorships Contract Number Program Name


1006SG2080 Baby City $4,996.00 1006GM2078 Back to School $ 4,542.00 1006GM2077 CARE $ 1,374.00 1006GM2079 Children’s Learning Center $ 3,066.00 1005GM0071 Classroom Environment and Early Learning $ 5,000.00 1006GM2075 Community Produce $ 4,986.00 1006GM2074 Improving the Quality of Program $ 2,297.00 1005GM0073 Library Resources $ 3,700.00 1005GM0062 Preschool Playground $ 5,000.00 1005SG0070 Reading is Fun Day $ 10,000.00 1006GM2076 School Readiness $ 4,996.00 1005GM0072 Speech/Language Development $ 4,950.00

6.7.3 Program Descriptions

Mini-Grants and Sponsorships: During FY 05-06, First 5 Fresno gave a total of 12 Mini-Grants and Sponsorships totaling $54,963.00 dollars. These projects were very diverse in scope and nature. The following offers a brief description on some of these Mini-Grants:

• Baby City provides community-based resources to pregnant and parenting foster youth, ages 14 to 21, through educational stations and workshops promoting healthy relationships, literacy, and child development. The Mini-Grant supported a resource and education event where at least 50 teen parents attended.

• Back to School focused on improving the quality of life and the development of children 3-5 in low- to moderate-income families by providing them with needed school supplies. The project is run by Saints Community C.O.G.I.C., which holds an annual fair on the church grounds. Other community organizations and agencies are invited to attend. The Mini-Grant supported the Back to School project by leveraging funds to offer school supplies to children in at least 6 schools.

• Improving the Quality of Program is a project run by the Stroller Moms English Program. The Mini-Grant was used to enhance the quality of the childcare program that accompanies the Stroller Moms English Program.

• Mobile Pantry Program is a project of the Community Food Bank. The Mini-Grant allowed the program to provide low-income individuals and families, who are in need of temporary food assistance, with fresh produce, dairy items, meat,



and various staple food items, including baby food for children 0-5.

Other Mini-Grants and Event Sponsorship projects included a preschool playground surfacing, purchase of tables for added work space, an event at Wild Water Adventure for foster children, expansion of a library, assemblage of speech and language therapy products, and enhanced classroom environment in a daycare setting.

Childcare Mini-Grants: There were a total of 149 Early Care and Education Providers receiving a Mini-Grant (117 family daycare homes and 32 center-based). Recipients received between $1,000 and $2,000, depending on the type of center. According to the Mini-Grants coordinator: “[f]amily childcare providers get $1000 grants, and the centers $2000.”16 When asked about the difference, she indicated that generally family childcare providers have a smaller place than centers, and therefore greater need. Providers requesting a grant are generally required to assess their workplace, whether family-based or center-based, using the Early Childhood Environmental Rating Scale, (Teachers College Press, 1998). This tool, also known as ECERS, allows the providers to rate their workplace using a scale, with various embedded “subscales.” Subscales include: Space and Furnishings; Personal Care Routines; Language-Reasoning; Activities; Interaction; Program Structure; and, Parents and Staff. According to the editors of the tool: “[t]he scale is design[ed] to be used with one room, or one group at a time, for children 2½ through 5 years of age.”17

The coordinator of this program stated in the Provider Annual Evaluation Report (PAER) that all Mini-Grant participants received four hours of training on how to use the scale and how to complete a self-evaluation on their center or home. She indicated that this tool was very useful for measuring the quality of the environment and for overall program improvement. As a result of this self assessment, Mini-Grant candidates, “were able to determine which areas needed improvement and therefore were able to purchase appropriate early childhood materials and/or furnishings.”18

Through the Mini-Grant Program, the quality of care among childcare centers and family daycare homes increased. [Mini-Grants Program Coordinator]

In addition to using ECERS, mini-grants recipients receive at least 4 hours of professional development training by attending a workshop at the Huggins Early Education Center at California State University, Fresno (CSUF). Some topics cited include: “curriculum, how to involve parents in their program, PITC topics, activities for infants and toddlers, and literacy.”19 According to the provider, “All workshop topics were on the importance of quality care and program improvement.”20 Below is a list of additional opportunities afforded to these mini-grant

16 Qualitative Studies Interview, LTG Associates, April 2006. 17 Early Childhood Environmental Rating Scale, Revised Edition, 1998. “ Introduction to the ECERS,” pg. 1. 18 Provider Annual Evaluation Report. 19 Ibid. 20 Ibid.


recipients as reported in the Provider Annual Report (PAER):

• Mini-Grant participants were able to tour the Huggins Center, which cares for children ages 3 months to 12 years to see examples of high quality environments.

• Mini-Grant participants received a site visit from the Mini-Grant Specialist to discuss quality improvement and any concerns or goals that they had. The Mini-Grant Specialist often helped participants select appropriate early childhood materials and/or furnishings. On many occasions more than one site visit was conducted to provide the Mini-Grant participant additional support and guidance.

• Special site visits were conducted with providers to assist in improvement of their environment for children with special needs. These participants received support through the LEADS program for inclusion and one-on-one support.

After the session I went home and redesigned my whole learning program and room. I put in small cozy nooks for the children, changed the look of the room, and threw out old outdated learning papers, cards, and things that were no longer inspiring to me or the children. I started to do documentation and listening to the children and they started to blossom.

The parents really appreciate the pictures and the enthusiasm that their children have when they come. I have been an Early Home Educator for more than 15 years and my husband said that he has never seen me so motivated as I have been after that day at the workshop. I just wanted to thank you and your staff for your inspiration and making me feel as though I do make a difference in a child’s life. [Childcare, Mini-Grant Recipient]

6.8 Conclusion As noted, the 48 Community-Based Initiative programs were divided among General Grants, Capital Grants, Mini-Grants and Event Sponsorships. General Grants provide funding for needs defined by community groups but which do not pertain to the ten Priority Outcomes. Highly diverse, the programs thus funded in 2005-2006 have in common their efforts to meet the needs of children 0-5 and their families. Capital Grants support capital projects benefiting children 0-5. Mini-Grants and Event Sponsorships support activities more limited in time and scope. Although the diversity of the activities funded under this program did not allow comprehensive outcome evaluation, process data show its wide reach.

6.8.1 General Grants Among all the Community-Based Initiatives required to submit the State Aggregate Data forms, the most common activity was providing Direct Services, most often through classes or workshops. These served 6,411 clients, providing almost 19,000 service contacts, almost a third of which were with children aged 0-5 years.

Next most common were initiatives focusing on Provider Capacity building. These provided training in serving clients with disabilities and special needs, addressing cultural diversity, and support for school readiness efforts. Initiatives for Community Strengthening were nearly as common. These relied most often on Community Events and Information Dissemination with the aim of increasing Community Resource Awareness.



Four programs used their funding for Infrastructure Investment. All four used the funds to build new facilities. The three programs focusing on Systems Change Support engaged largely in Organizing Meetings to Share Information, Coordinate or Make Decisions and using other methods to promote interagency collaboration.

6.8.2 Capital Grants In addition to the General Grants used for infrastructure improvement, three Capital Grants were awarded for infrastructure improvements in County schools.

6.8.3 Mini-Grants and Event Sponsorships Although the amounts given for these initiatives were small, they reached many recipients, including 149 providers of early care and education, and they funded many types of activities, from surfacing playgrounds to providing excursions for foster children.



Chapter 7 OVERARCHING PERSPECTIVES

7.1 Introduction This chapter highlights elements that First 5 Fresno focused on for this Fiscal Year. There are other important concerns that have been addressed in previous Fiscal Years, such as tobacco prevention and advocacy, but they are not part of this year’s funding.

7.2 Service Integration First 5 Fresno has been striving to achieve a level of service integration that is supportive of children 0-5 and their families throughout Fresno County. Some of the key strategies have been to:

• Open points of access to services through existing programs; • Fund key services that may result in cross referrals; and, • Make long-term investments in communities outside of the city of Fresno.

A good example of how service integration has become part of the day-to-day activities of the programs that First 5 funds is the way in which School Readiness programs have become “points of access” for services for children and their families. School Readiness programs provide a variety of services that include parent workshops for family support. Many of the School Readiness programs bring other First 5 providers to their sites to offer additional information or additional services to parents. Thus many of these “host” School Readiness programs become points of access for a variety of services offered by other First 5 programs or other non-First 5 funded services in the community.

Some School Readiness programs operate as part of a Neighborhood Resource Center (NRC). NRC services have created a safety net for entire families as children enroll in school readiness activities, such as K-Camp, preschool services, enriched childcare or home visitation, and social services referrals and support. Service integration in these cases extends to support the overall well being of children 0-5 beyond the educational component.

Likewise, service integration within First 5 programs can be described at this point as dynamic and rapidly moving towards uniformity. For instance, many programs are actively providing referrals or facilitating referrals for families in their programs. This has enabled many families with children 0-5 to connect to health and social services as well as enriched childcare.

Service integration has also been achieved in part as communities have benefited from programs, services, or best practices that have been conducted in their neighborhoods, using a more decentralized model. As these programs “integrate” into communities, First 5 Fresno is able to touch more lives of children 0-5 and their families. This level of integration can be described as long term and essentially geared towards benefiting children and families that would otherwise lack access to quality care or key services to support child development and school readiness.


One example of the latter is the Community Youth Ministries—Learning Center in the city of Reedley. Reedley is approximately 30 miles south of the city of Fresno with a population of about 20,000 people. The Learning Center became a licensed childcare facility with the support from First 5. The Learning Center provides care to children 0-5 whose mothers are teenagers. They now serve 24 preschoolers and 12 infant/toddlers. The program primarily assists teen parents who are unable to afford quality childcare while they pursue college careers and vocational goals. The program also connects these parents with services outside Reedley. CYM, as Community Youth Ministries is known, has brought many long-term benefits to the community and to the program. One provider stated:

It is very difficult to express the benefits of what the First 5 funding has allowed CYM to do through this past year. There really is so much and we are very thankful for it. Our moms are very excited, as they have been waiting years for this daycare to open! Now that day has arrived and it is still sinking in – finally, the dream turned into reality!

The community of Reedley has been so great and supportive of our Teen Mom Program as a whole. They have “adopted” our café, which we are opening for the same moms that are served through the daycare. They have donated paint, a brand-new porch, equipment, and hundreds of volunteer hours spent fixing up our Fresh Start Café. The moms themselves have also spent many hours cleaning and fixing up the café. They are as invested in the café as they are the daycare. We have had many Reedley Exponent [newspaper] articles about our program and get many phone calls each week from community members, wondering when we are opening! It is our hope that the café will not only pay for itself, but eventually help pay for the daycare. Without the funding from First 5 that enabled the daycare to open, we literally could not have come this far – no exaggeration! (Renee Harder, Annual Report).

7.3 Accessibility of Services First 5 has addressed access issues by funding programs that either serve a particular population that may have limited access to services due to linguistic or cultural barriers, or funding

programs that make services accessible to children with special needs and their families. Geographically, First 5 Fresno has extended its reach to monolingual and special needs communities within the County but outside the city of Fresno. Many of these monolingual and special needs communities face substantial access barriers because of their distance from many major services that are concentrated in the city of Fresno. Some examples of organizations that are trying to bring needed services to these communities are: the Slavic Kids in Focus, focusing on Russian/Ukrainian families; the Khmer Society, providing home visitation services to Khmer

families; Bridge to Empowerment, working with children who are deaf or hard of hearing; and, Coalinga Family Resource Center, which provides resources and referrals to parents with children with special needs in the area.

Some programs centrally located in the city of Fresno actively deliver services to other communities, traveling throughout the County to deliver services or even bringing families into



Fresno for services. On the other hand, cities such as Huron, Coalinga, Orange Cove, Caruthers, Firebaugh, Reedley, Five Points, Selma, Sanger, and Del Rey have First 5 programs located locally, making services readily accessible to their remote communities.

Another good example of how First 5 has prioritized ensuring accessibility of services is funding specific programs to provide services to children with special needs. Programs that primarily do so include the Assessment Center for Children (ACC), (see section 5.3 above), Bridge to Empowerment, Deaf Families Reading Together, Coalinga Family Resource Center, and Healthy Steps. In addition, First 5 integrated the usage of two developmental assessment tools, Ages and Stages Questionnaire (ASQ) and Ages: Social and Emotional (ASE), into other key programs, particularly those in the School Readiness Initiative and Home Visitation programs. As a result, a total of 1,342 developmental screenings were conducted across all First 5 programs using these instruments during the fiscal year. This meant that more children obtained early screening and were connected to needed services.

7.4 Cultural/Linguistic Responsiveness First 5 funds a variety of programs in order to create cultural and linguistic responsiveness. Examples of such programs funded by First 5 are: the Mixteco program; the Slavic Kids in Focus; Abuelitas y Mamacitas (Grandmas and Moms); and, Khmer Society.

Describing the Abuelitas y Mamacitas (AyM) program, the provider said:

The AyM [Abuelitas y Mamacitas] program has a client base of 100% Latino, serving the southwestern rural Fresno County community of Huron. 90% of our Mamacitas are Spanish speaking only and of the children enrolled, 85% are non-English speaking with 15% of the…children having limited English-speaking skills. All clients in the AyM program are farm workers and are below poverty level. [Abuelitas y Mamacitas Provider]

The program uses the “grandma’” cultural icon in the Latino community as a key resource to teaching younger moms parenting skills, including child development, education, and nutrition.

They [Abuelitas y Mamacitas families] are served culturally and linguistically appropriate by having Spanish speaking presenters or translators, and given appropriate information in Spanish that are selected on the locally based needs of the individual families. [Abuelitas y Mamacitas Program Coordinator]

7.5 Organizational and Provider Network Capacity First 5 continues to convene and facilitate networks by participating and organizing meetings for providers serving children 0-5. During FY 05-06, First 5 organized at least 12 monthly coordinator meetings for providers in the School Readiness and Home Visitation programs. First 5 also facilitated sessions providing information from experts in child development and other related disciplines to give providers direct access to best practices in the field.


In addition, First 5 staff continued to facilitate meetings with community members to discuss potential partnerships and solidify others. One example is the Special Needs and Assessment Center for Children Initiatives. Providers meet periodically to discuss how to improve access and support families with children with special needs in Fresno County.

Similarly, First 5 has been able to coordinate and mobilize community leaders to increase the County’s capacity to support the needs of children 0-5. A clear example of the latter is the extensive work that First 5 staff and consultants hired by the Commission focused on facilitating the re-structure of the Children’s Health Initiative. First 5 Fresno has facilitated the Assessment Center for Children assessment of roles and responsibilities in an effort to improve their capacity, leading to greater efficiency in the delivery of services to children and families in the County.

7.6 Long-term Impacts of First 5 Services LTG Associates has begun to look into the long term impacts that services funded through First 5 Fresno have had and anticipate having for children 0-5 and their families in Fresno County. So far, the incorporation of the qualitative studies has allowed us to begin exploring the ripple effect that programs such as the School Readiness Initiative have on families and children not directly participating in First 5 Fresno funded programs. The results are promising.

Within the last FY and as the evaluation framework has been implemented, baselines have been created. It is anticipated that during the following Fiscal Year (06-07), additional data will give us a much anticipated view of the outcomes of First 5 Fresno programs in the lives of children and their families.

Documents

Annual First 5 Fresno County Evaluation Report, 2005-2006 ... FFF 05-06 Annual Evaluation...Evaluation Report, 2005-2006 of the First 5 Fresno staff and providers A Report to the Children