Minnesota

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Minnesota Strategies
Risk Factor Screening for Vulnerable Children and Families: Minnesota Family Navigators

The Minnesota Department of Human Services has adopted a community-based approach to child abuse and neglect prevention that builds family strengths and addresses critical family needs. A key component of this approach has been the use of family navigators who work with families to identify strengths and needs across a range of domains–including child development, parent mental health, child care access and support, housing stability, transportation, and food security–and help connect families to services and supports. This profile describes how Minnesota has supported family navigators in Community Resource Centers and describes implementation of family navigation approaches in two parts of the state: Minneapolis and Cook County.

Support for family navigators began under the state’s federal Preschool Development Grant Birth through Five (PDG B-5), which funded Community Resource Hubs (CRHs) through 13 community-based partnerships. The CRHs pursued relationship-based prevention strategies that responded to local communities’ needs, and family navigators played a central role in achieving those aims. Following the end of the PDG B-5 grant in 2023, the state legislature appropriated $5.6 million in 2023 to continue the CRH approach for three years by funding Community Resource Centers (CRCs). CRCs are community-based entry points providing culturally responsive, relationship-based family navigation and other supportive services. Grants will be awarded to between 7 and 18 CRCs to deliver family navigation services within community-based organizations beginning in August 2024; many former CRH grantees have applied for CRC grants.

Local population data are used to identify locations for CRCs, particularly census tracts and zip codes with higher rates of poverty and reports of child abuse and neglect, and fewer child care programs This approach ensures CRCs will reach those with the greatest need while also allowing them to develop family navigation approaches tailored to those needs.

Family navigators build trusting relationships with families, identify resources and programs in the community, and connect families to community supports that address their needs and meet their goals. A prerequisite to building trust is that families’ with family navigators is voluntary, and they have no formal relationship with the child welfare system. To engage families, navigators employ a range of strategies, with CRCs given flexibility to develop approaches customized to their communities. Common approaches to recruiting families include holding or having a presence at community events, offering gift cards, and relying on word of mouth recommendations. CRC grantees are required to have local parent councils to guide their work, including developing community engagement strategies. The referral relationships that family navigators develop with local service providers also serve as a source of referrals back to the family navigators.

When families meet with a navigator, the navigator works to understand the family’s situation, including strengths and needs. In some cases, the family has a particular basic need, such as diapers or food, that that the navigator can quickly help a family obtain. Following these interactions, families are more likely to return to the navigator if they have additional, more open-ended or complex needs in the future. While navigators are not required to use particular screening tools or instruments to identify family needs, they are encouraged to use the Center for the Study of Social Policy Protective Factors Framework, which identifies five characteristics that increases the likelihood of positive family outcomes and reduces the likelihood of child abuse and neglect.

Family navigators can use various methods to identify community partners that may be able to assist families. If families have concerns about child development, the navigator can refer them to Help Me Grow, which offers child development screening and referrals. For parent mental health needs and concrete needs such as housing, food, transportation, child care, and public assistance, Minnesota has developed Help Me Connect (HMC). HMC allows the navigator to conduct a search for resources within different zip codes to find services that meet family needs. Navigators can also use Bridge to Benefits, a web tool developed by Children’s Defense Fund Minnesota, which identifies family eligibility for various health and financial stability benefits, such as Medicaid, SNAP, and energy assistance. Navigators can directly support families’ application for public benefits by using MN Benefits, an online common application for nine financial stability programs. Many families receive warm handoffs, where the navigator will work directly with the family and service provider to support the referral process. This process helps build relationship with the family as well as with the referral partner. Navigators routinely follow up with families to determine if referrals have helped address their needs.

Family navigators’ success depends on the relationships they develop with other community-based partners that can provide supports to families. Often the navigator will be located within an organization that provides services such as early care and education, healthcare, parenting support, basic needs, or economic stability supports such as housing, food, and TANF. For other services, navigators focus on identifying partners who provide relationship-based, culturally responsive care. Typical community partners include early care and education providers, healthcare and mental health providers, and religious institutions. In turn, these partners are able to refer families to the navigator if they become aware of needs they are not able to address.

Minnesota also supports family navigation through two additional targeted efforts. As part of the CRC request for proposals, the state is also offering grants for a kinship navigation program funded through the Family First Prevention Services Act. Kinship navigation services must be provided to kinship caregivers using an approved evidence-based model. Minnesota uses its federal Community-Based Child Abuse Prevention grant funds to deliver its Parent Support Outreach Program (PSOP) through county child welfare offices to at risk families not currently involved with child protection services. PSOP offers case management and service navigation to families, most of whom have been referred after having been screened out of child protection services.

Workforce Development

The individual CRCs are responsible for determining the qualifications of the family navigators they hire, though the state will encourage CRCs to recruit navigators with lived experience in the communities they serve. State-provided navigator training includes use of the HMC, Bridge to Benefits, and MN Benefits online tools.

Under the PDG B-5 grant, the state provided mental health consultation to navigators, which they greatly valued as a support to sustaining their practice. The consultation involved training and reflective supervision to help navigators address child and family mental health needs. The state also offered navigators community of practice sessions, which allowed navigators and other CRH staff to discuss challenges, identify solutions, and share successful strategies. Quarterly meetings with the CRHs and the state provided additional opportunities to share updates, learn about common topic across CRHs, and raise issues with the state. The state will continue these supports for CRC grantees.

Financing

Funding for CRHs under the PDG B-5 grant to 12 grantees was $6 million for three years from 2019 through June 2023. CRC funding of $5.6 million from a state appropriation for CRC grantees begins in August 2024. In the interim, organizations have pursued a number of strategies to continue funding family navigators, including use of the agencies’ own funds and partnering with philanthropies.

Monitoring and Evaluation

An evaluation conducted as part of the PDG B-5 grant examined the characteristics of families served by navigators and families’ requests for support. Data were collected from quarterly reports submitted by CRHs. Between July 2021 and September 2022, CRHs served nearly 10,000 families, almost half of whom were Black, Indigenous, Latinx, and Asian. The most frequently sought services were: food (20 percent), child care access (15 percent), financial assistance (e.g., TANF and SNAP, 15 percent), housing (13 percent), and family well-being (including mental health, nine percent.),

The community of practice and other ongoing supports offered by the state provide opportunities for navigators to refine their approaches to engaging and interviewing families, as well as ensuring successful referrals. They also allow navigators to identify barriers the state could address through policy change (e.g., there are insufficient local mental health providers able to serve family needs).

Minneapolis Youth Coordinating Board

The Minneapolis Youth Coordinating Board (MYCB) has partnerships with six local sites to deliver family navigation services. Three are on the north side of Minneapolis, serving mainly African-American families. Of the three on the south side, one serves Somali families, one serves Spanish-speaking families, and one serves Native American families. All the navigators are located full-time in child care centers, apart from the navigator who works with Somali families and is based in the Cedar-Riverside neighborhood.

For the navigators based in child care centers, many of the families they work with have children attending the centers. Navigators know the language and culture of the communities they serve, and they are able to build relationships with families they see regularly at the center. The centers invite local family, friend, and neighbor (FFN) child care providers to trainings offered to center staff and in-house field trip events for children, which allows navigators to build relationships with these FFN providers who refer families. Additional referrals come from the Minneapolis public school system through its early childhood screening program, which recommends a preschool screening at age three and requires one before a child enrolls in kindergarten. They also connect with families through word-of-mouth recommendations and advertise on social media and through flyers at neighborhood community organizations. While some families in unfounded cases are referred by child welfare, navigators generally stress their independence from child welfare, which help them build trusting relationships with families.

In the Somali community, the navigator conducts home visits with families with children under 12 and also offers weekly three-hour family gatherings on Sundays with parent education sessions and activities for children. At these gatherings the navigator can help families apply for public benefits such as WIC and SNAP.

While navigators use simple forms to gather basic information about families, they predominantly learn about family needs through their ongoing interactions with them rather than through formal screening tools. Especially for families with children attending the early childhood centers, the navigators see them every day and are a regular presence in their lives. For families referred from the community, especially through word-of-mouth, initial interactions are often based on addressing a specific need (e.g., help with a car repair or locating a food pantry) and can then develop into an ongoing relationship.

Navigators use Help Me Grow, Help Me Connect, Bridge to Benefits, and MN Benefits to support families. They also maintain their own lists of local resources, such as shelters and churches that offer food assistance. The most common needs they help families address are related to food (WIC, SNAP, food pantries), transportation, and housing (including furnishing). Navigators can also refer families to pro bono immigration lawyers.

Families report a range of mental health needs, and navigators can help connect them to providers such as The Family Partnership, which offers parenting and mental health services. However, waiting lists with mental health providers, a lack of health insurance coverage, and stigma around seeking support, especially in cases of addiction, can hinder access to parent and child mental health treatment. Building trust between navigators and families is an important factor in overcoming stigma associated with mental health challenges and addiction.

Navigators can also refer families to home visiting programs, including Early Head Start offered by two of the centers, as well as to parenting classes offered by school districts and the early childhood centers. The early childhood centers typically offer six-week classes two times a year, and navigators help select topics based on conversations with parents about their needs.

Workforce Development

Partner sites hire, employ, and supervise the navigators and receive reimbursement for their salaries from MYCB. Supervisors at the early childhood centers and MYCB partner to provide training for navigators which includes quarterly trainings and regular reflective supervision. They can also participate in joint trainings with Family Resource Center staff and Minneapolis public school staff offered by MYCB.

Financing

MYCB originally funded the navigators through PDG B-5 Funding for Community Resource Hubs and has applied for Community Resource Center funding from the state. In the interim, MYCB funds the navigators through private funding.

Monitoring and Evaluation

Under the PDG B-5 grant, navigators submitted quarterly reports on referrals as part of the evaluation, but MYCB does not currently have the resources for data collection and analysis. MYCB has conducted parent focus groups to learn about their greatest concerns, which helps navigators identify and partners with local services and organizations that address those concerns.

Sawtooth Mountain Clinic

Sawtooth Mountain Clinic (SMC) is a federally qualified health center based in Grand Marais and serving rural Cook County. Cook County has a population of about 5,000 people and includes the Grand Portage Indian Reservation. There are approximately 250 children under age five and about 40-50 births a year. In addition to SMC, there is a local dental office and clinic on the reservation; the closest specialty healthcare services are in Duluth, 2.5 hours away by car.

SMC currently has one part-time family navigator who is based on-site in the clinic. The most common source of referrals to the navigator is from providers within the clinic, including physicians and the county home visiting nurse. Other referral sources from community partners include tribal Head Start, Head Start and preschool, the elementary school and its Early Childhood Family Education program, and county public health. SMC also organizes free community outreach events to connect families with the navigator. Family socials on the first Saturday of the month have offered activities such as oral health screenings, children’s book author events, and snacks.

The navigator can meet with families on-site at SMC, although many interactions with families are conducted over the phone, which is typical for rural areas. Through conversations with families the navigator learns about their needs. Because information on Help Me Connect is not always up to date. The navigator maintains and updates a directory of local resources for families.

Two of the most common resources the navigator refers families to are rental assistance and heating assistance. The navigator can also support parents of children with special needs to obtain services in school and through specialty healthcare providers. For parents with concerns about child development, the navigator can refer families to the local school for early intervention and early childhood special education evaluations.

The navigator can refer to local home visiting programs. Perinatal universal home visiting is offered by the public health nurse and most families receive at least one visit. Longer-term home visiting is offered using the Maternal Early Childhood Sustained Home-Visiting (MECSH) model.

Mental health is another commonly identified need, and the navigator can refer families to one of SMC’s four clinical social workers. One clinician also offers Child-Parent Psychotherapy (CPP), an evidence-based dyadic treatment model (see the PRiSM evidence summary on dyadic treatment for more information), to address infant-early childhood mental health needs. However, only about 10 families have been served by CPP in the past four years and families have found it challenging to complete the full course of treatment, which can involve weekly sessions for up to a year, because of working multiple jobs, inconsistent child care, and other logistical challenges. SMC offers care coordination, gas cards, and evening hours to accommodate CPP families.

Financing

Following the end of PDG B-5 funding for navigation through the CRH, SMC has partnered with the North Shore Health Care Foundation for current funding for the navigator and to apply for the CRC grant opportunity to receive state funding.

Monitoring and Evaluation

As part of the CRH grant, Wilder Research conducted a needs assessment for SMC to identify the families’ awareness of local supports, challenges accessing them, and their needs. The highest priority needs were child care access, peer connections, and early childhood mental health services. If SMC gets a CRC grant, it hopes to engage in research to better identify whether there are families who are not engaging with the navigator who could benefit.

Special thanks to the following individuals for providing information for and reviewing this profile: Megan Waltz, Minnesota Department of Human Services, Promotion and Prevention Unit; Deby Ziesmer, Minneapolis Youth Coordinating Board; and Kate Surbaugh, Sawtooth Mountain Clinic.

Last updated August 2024

Child Social-Emotional Screening and Response

Minnesota has developed a comprehensive system of policies and supports for social-emotional screening of infants, toddlers, and preschoolers. Social-emotional screening is promoted in pediatric settings through the state’s EPSDT program and several other initiatives that serve young children, including: the Follow Along Program for children birth to 36 months; the Minnesota Department of Education’s Early Childhood Screening Program for three-year-olds through kindergarten-aged children; Early Head Start and Head Start; and child welfare which requires social-emotional screening of young children who receive protective services or are in out-of-home placements. Clear policies and protocols help ensure effective screening across programs in this system. 

  • Guidance for providers in pediatric settings recommend a minimum of seven social-emotional screenings through age four, with additional social-emotional screenings provided and billable, as needed.
  • In the Follow Along Program, operated through local public health departments, a nurse or other professional invites parents (by phone or a home visit) to complete ASQ-SE and ASQ screenings on a regular basis, shares results with parents, and helps them connect with a provider for an evaluation if social-emotional or developmental concerns are identified.
  • All children are required to have social-emotional and developmental screening for participation in kindergarten programs and can receive these through the MN Department of Education’s Early Childhood Screening Program for three-year-olds through kindergarten-aged children; outreach materials are translated into seven languages.
  • Children who receive protective services or are in out-of-home placement must receive a mental health screening with the ASQ-SE or Pediatric Symptom Checklist, and follow-up diagnostic assessment and treatment if needed; these children are typically screened by the child welfare agency.

The Minnesota Interagency Developmental Screening Task Force conducts rigorous reviews of child screening instruments and provides guidance on developmental and social-emotional screening of children from birth through five for public screening programs. Members of the Task Force include representatives from the Departments of Health, Human Services, and Education. The Task Force has created online guidance about recommended screening instruments. This guidance identifies the Ages and Stages Questionnaires: Social-Emotional, 2nd edition (ASQ:SE-2) as the recommended screening tool for children under age four and the Pediatric Symptom Checklist and ASQ:SE-2 for children ages four and five in public screening programs. 

The Task Force also offers guidance on referral and follow-up for young children who have positive social-emotional screens. One resource explains how primary care and school-based providers (e.g., preschool, preschool special education) can share child-specific data to coordinate referrals based on HIPAA and FERPA (federal health care and educational data privacy laws). Providers and staff in pediatric settings, early care and education, child welfare, home visiting, as well as parents, are encouraged through multi-language outreach materials to refer children for screening and follow-up services through the state’s Help Me Grow (HMG). In Minnesota, HMG connects families to the child’s local school district for further screening, evaluation and service coordination. The Task Force has developed training resources on social-emotional screening. These include a curriculum with PowerPoint slides and notes that cover developmental and social-emotional screening, referral, and linkage to services as well as web-based and in-person trainings. 

Financing

Sources for funding to conduct screening include Medicaid, Title V, Part C (IDEA), and state appropriation. 

Monitoring and Evaluation

Most public screening programs in Minnesota collect annual data on the number of children screened by characteristics that include age, race/ethnicity, and primary language, as well as referral rates. In 2018, school districts screened 64,000 children statewide; the screening rates among three- and four-year-olds were 38% and 34%, respectively. Head Start completed 17,000 screenings in 2018, and public health completed 10,500. The social-emotional screening rates in EPSDT visits were 14% for infants (under 1 year), 8% for children ages 1-2 years, and 16% for children ages 3-5 years in 2017. The screening rates may be under-reported as many providers are not aware that the state’s Medicaid covers social-emotional screens (unlike private insurance), and are not billing Medicaid for those screens. 

An evaluation of screening and referral practices in pediatric settings examined practices that had participated in an ABCD project which promoted screening with training and resources. This project, a retrospective medical record review of five primary care clinics, found that practices incorporated evidence-based social-emotional and developmental screening into their practices and made frequent referrals to HMG based on screening and parent concerns. However, documentation of follow-up to ensure completion of the referral and outcome was less consistent; for about one-quarter of the referred children, there was no follow-up information in charts.

Last updated October 2019

Effective Assessment and Diagnosis (DC:0-5)

The Minnesota manual for Medicaid providers recommends that mental health professionals conducting diagnostic assessments use the Diagnostic Classification of Mental Health Disorders of Infancy and Early Childhood with children under age 5. In July 2018, the state officially established a requirement for providers’ use of the current version, DC:0-5, and is in the process of revising statute language to reflect the change. The State has developed a cross-walk between DC:0-5 and ICD codes to facilitate billing. Prior to a standard diagnostic assessment, clinicians have the option to conduct three pre-diagnostic assessment sessions and collect all necessary information specified under the DC:0-5 framework. Alternatively, a clinician can conduct and bill for an extended assessment conducted over three or more sessions. 

Training on the DC:0-5 is offered through the state’s Adult & Children’s Mental Health Learning Center. An in-person introductory course on the DC:0-5 consisting of three full-day sessions is offered five times throughout the year. The first day of the course focuses on child development, and the subsequent days cover DC:0-5 and Medicaid compliance. Clinicians who complete the DC:0-5 training can participate in a free consultation group for additional support. The consultation group, called “Great Start Clinician’s Group,” meets via teleconference every month. Up to 300 participate monthly in the Great Start Clinicians’ Group. The group provides opportunities for clinicians to discuss cases, especially difficult ones, and hone their assessment skills. In addition, the Minnesota Department of Human Services has created additional diagnostic resources to assist clinicians, including Diagnostic Assessment Decision Tree for Children 0-5 and How to Gather Information for the DC:0-5 Five Axes. By August 2019, the state had trained 3,000 mental health professionals in the use of DC:0-5. 

In an effort to build the workforce, Minnesota allows clinical trainees to conduct diagnostic assessments and bill at the same rate as their supervisors. The state Medicaid clearly defines who qualifies as clinical trainees in its provider manual. In addition, the Behavioral Health Division launched an effort to train university faculty on DC:0-5 in 2016. Faculty participating in the training came from 11 different universities across the state and represented the fields of psychology, psychiatry, developmental pediatrics, social work, clinical counseling, and marriage and family. The one-day training integrated the Zero to Three curriculum. 

Financing

The state funds all DC:0-5 trainings and the Great Start Clinician’s Group meetings through its Federal Mental Health Block Grant. Providers who are early childhood mental health grantees can receive payment for billed hours they lose to training participation through a state appropriation. 

Last updated October 2019

Special thanks to Catherine Wright, Early Childhood Mental Health System Coordinator, Behavioral Health Division, Minnesota Department of Human Services, for providing information for and reviewing this profile.