United States General Accounting Office
___________________________________________________________________
GAO Report to the Chairman, Subcommittee
on Labor, Health and Human Services,
Education and Related Agencies,
Committee on Appropriations
U.S. Senate
___________________________________________________________________
July 1990 HOME VISITING
A Promising Early Intervention
Strategy for At-Risk Families
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Jack L. Brock, Jr.
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Government Information and Financial
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Information Management and Technology Division
B-238394
July 11, 1990
The Honorable Tom Harkin
Chairman, Subcommittee on Labor, Health and Human
Services, Education, and Related Agencies
Committee on Appropriations
United States Senate
Dear Mr. Chairman:
This report, prepared at the Subcommittee's request, reviews
home visiting as an early intervention strategy to provide
health, social, educational, or other services to improve
maternal and child health and well-being.
The report describes (1) the nature and scope of existing
home-visiting programs in the United States and Europe, (2)
the effectiveness of home visiting, (3) strategies critical to
the design of programs that use home visiting, and (4) federal
options in using home visiting.
This report contains a matter for consideration by the
Congress and recommendations to the Secretaries of Health and
Human Services and Education.
As agreed with your office, unless you publicly announce its
contents earlier, we plan no further distribution of this
report until 30 days from the date of this letter. At that
time, we will send copies to the Secretaries of Health and
Human Services and Education and to interested parties and
make copies available to others upon request.
This report was prepared under the direction of Linda G.
Morra, Director, Intergovernmental and Management Issues, who
may be reached on 275-1655 if you or your staff have any
questions. Other major contributors to this report are listed
in appendix V.
Sincerely yours,
Charles A. Bowsher
Comptroller General
of the United States
1
EXECUTIVE SUMMARY
-----------------
PURPOSE
-------
Families that are poor, uneducated, or headed by teenage parents
often face barriers to getting the health care or social support
services they need. Many experts believe that an effective way
to reduce barriers is to deliver such services directly in the
home. This is known as home visiting. They also believe that
using home visiting to deliver or improve access to early
intervention services--prenatal counseling, parenting
instruction for young mothers, and preschool education--can
address problems before they become irreversible or extremely
costly.
Is home visiting an effective service delivery strategy? What
are the characteristics of programs that use home visiting? Are
there opportunities to expand the use of home visiting? The
Senate Appropriations Subcommittee on Labor, Health and Human
Services, Education, and Related Agencies asked GAO to answer
these questions.
BACKGROUND
----------
Home visitors have worked with families in the United States and
Europe for more than 100 years. In-home services began when
public health officials recognized that proper prenatal and
infant care could reduce infant deaths. Home visitors provide a
variety of services--prenatal visits, health education, parenting
education, home-based preschool, and referrals to other agencies
and services.
While home visiting can also be used to deliver services to the
chronically ill and the elderly, this report focuses on
delivering early intervention services to at-risk families with
young children. For this study, GAO reviewed the home-visiting
literature; interviewed international, federal, state, and local
program officials and other experts in medical, social, and
educational service delivery; and reviewed eight programs in the
United States, Great Britain, and Denmark that used home
visiting.
RESULTS IN BRIEF
----------------
Home visiting is a promising strategy for delivering or improving
access to early intervention services that can help at-risk
families become healthier and more self-sufficient. Evaluations
have demonstrated that such services are particularly useful when
families both face barriers to needed services and are at risk
of such poor outcomes as low birthweight, child abuse and
neglect, school failure, and welfare dependency. While few cost
studies of home visiting have been done, they have shown that
2
delivering preventive services through home visiting can reduce
later serious and costly problems. But the cost-effectiveness of
home visiting, compared to other strategies to provide early
intervention services, has not been well researched.
Not all programs that use home visiting have met their
objectives. Success depends on a program's design and operation.
Well-designed programs share several critical components that
enhance their chances of success. Home visiting does not stand
alone; much of its success stems from connecting clients to a
wider array of community services.
The federal government's home-visiting activities can be better
coordinated and focused. The Departments of Health and Human
Services (HHS) and Education provide funding for various home-
visiting services and initiatives. But the knowledge gained
through these efforts is not always shared across agencies and
with state and local programs. The federal government is
uniquely situated to strengthen program design and operation for
home visiting by communicating the wealth of practical knowledge
developed at the federal, state, and local levels.
GAO'S ANALYSIS
--------------
Home Visiting Can Be an Effective Service Delivery Strategy
-----------------------------------------------------------
Evaluations of early intervention programs using home visiting
demonstrate that these programs can improve both the short- and
long-term health and well-being of families and children.
Compared to families who were not given these services, home-
visited clients had fewer low birthweight babies and reported
cases of child abuse and neglect, higher rates of child
immunizations, and more age-appropriate child development.
Evaluations of home visiting that examined costs have
demonstrated its potential to reduce the need for more costly
services, such as neonatal intensive care. However, few
experimental research initiatives have compared the cost-
effectiveness of home visiting to that of other early
intervention strategies.
Successful programs usually combined home visiting with center-
based and other community services adapted to the needs of their
target group. Longitudinal studies showed that visited families
showed lasting positive effects, including less welfare
dependency.
Characteristics That Strengthen Program Design and Implementation
-----------------------------------------------------------------
Although many early intervention programs using home visiting
have succeeded, others have failed to meet their stated
objectives. Evaluators have attributed such failures to
fundamental problems with program design and operation. GAO
3
identified critical design components for developing and
managing programs using home visiting that include (1)
developing clear objectives and focusing and managing the
program in accordance with these objectives; (2) planning service
delivery carefully, matching the home visitor's skills and
abilities to the services provided; (3) working through an
agency with a capacity to deliver or arrange for a wide range of
services; and (4) developing strategies for secure funding over
time.
Federal Commitment Can Be Better Coordinated and Focused
--------------------------------------------------------
HHS and Education support home visiting through both one-time
demonstration projects and ongoing funding sources, such as
Medicaid (a federal-state medical assistance program for needy
people). But federal managers were not always aware of results
in other agencies, materials developed through federally funded
efforts, or state and local home-visiting efforts.
The Federal Interagency Coordinating Council is a multiagency
body that attempts to mobilize and focus federal efforts on
behalf of handicapped children or those at risk of certain
handicapping conditions. The Council is one federal mechanism
that can be used to better disseminate information on successful
home-visiting efforts and encourage collaboration on joint agency
projects.
Federal demonstration projects could be better focused to improve
program design and fill information voids. Federal managers
should emphasize evaluating potential cost savings associated
with programs using home visiting and developing strategies to
*better integrate home visiting into community services,
especially beyond federal demonstration periods.
The Congress' recent interest in home visiting has focused on
maternal and child health initiatives, including newly
authorizing home-visiting demonstration projects through the
Maternal and Child Health block grant. The Congress considered
(but did not pass) legislation to amend the Medicaid statute to
explicitly cover physician-prescribed home-visiting services for
pregnant women and infants up to age 1. The Congressional Budget
Office estimated that the additional federal fiscal year 1990-94
Medicaid costs for this initiative would range from $95 million,
if home visiting were made an optional Medicaid service, to $625
million, if mandatory.
MATTER FOR CONGRESSIONAL CONSIDERATION
--------------------------------------
In view of the demonstrated benefits and cost savings associated
with home visiting as a strategy for providing early intervention
services to improve maternal and child health, the Congress
should consider amending title XIX of the Social Security Act to
4
explicitly establish as an optional Medicaid service, where
prescribed by a physician or other Medicaid-qualified provider,
(1) prenatal and postnatal home-visiting services for high-risk
women and (2) home-visiting services for high-risk infants at
least up to age 1.
RECOMMENDATIONS
---------------
GAO recommends that the Secretaries of HHS and Education require
federally supported programs that use home visiting to
incorporate certain critical program design components for
developing and managing home-visiting services. The Secretary of
HHS should specifically incorporate these components into the
Maternal and Child Health block grant home-visiting demonstration
projects.
GAO further recommends that the Secretaries
-- make existing materials on home visiting more widely available
through established mechanisms, such as agency clearinghouses,
-- provide technical or other assistance to more systematically
evaluate the costs, benefits, and potential cost savings
associated with home-visiting services, and
-- charge the Federal Interagency Coordinating Council with the
federal leadership role in coordinating and assisting home-
visiting initiatives.
AGENCY COMMENTS
---------------
HHS and the Department of Education generally concurred with
GAO's conclusions and recommendations. Both agreed with the need
for more research and evaluation of the costs and benefits of
home visiting. Without such data, they expressed reluctance to
give priority to home visiting over other early intervention
service delivery strategies. Education supported the Council as
a focal point for federal home-visiting activities, although HHS
believed it to be beyond the scope of the Council's mission. In
regard to establishing home visiting as an optional Medicaid
service, HHS stated that states essentially have the option now
to cover home visiting under a variety of Medicaid categories of
service. GAO believes, however, that amending the Medicaid
statute to explicitly cover home visiting as an optional service
would send a clear message to states about the efficacy of home
visiting, especially for high-risk pregnant women and infants.
5
CONTENTS
--------
Page
----
LETTER 1
EXECUTIVE SUMMARY 2
CHAPTER 1 INTRODUCTION 10
What Is Home Visiting? 10
Some Families Face Service Barriers 11
Home Visiting as an Early Intervention 13
Strategy
Objectives, Scope, and Methodology 15
CHAPTER 2 HOME VISITING IS AN ESTABLISHED SERVICE 17
DELIVERY STRATEGY WITH MULTIPLE OBJECTIVES
Home Visiting Widespread in Europe 17
U.S. Home Visiting Targeted to Low-Income 19
and Special Needs Families
Funding for U.S. Home Visiting From 21
Multiple Agencies
New Impetus for Home Visiting From Recent 24
Legislation
CHAPTER 3 HOME-VISITING EVALUATIONS DEMONSTRATE 30
BENEFITS, BUT SOME QUESTIONS REMAIN
Program Evaluations Show Benefits 30
of Home Visiting
Research Shows Home Visiting Compared to 37
Other Strategies Promising, but
More Study Is Needed
Limited Research Shows Home Visiting 38
Can Produce Cost Savings
CHAPTER 4 POOR PROGRAM DESIGN CAN LIMIT 42
BENEFITS OF HOME VISITING
Poor Program Outcomes Linked to 42
Design Weaknesses
6
Critical Components for Program 46
Design
CHAPTER 5 A FRAMEWORK FOR DESIGNING PROGRAMS 47
THAT USE HOME VISITING
Clear Objectives as a Cornerstone 49
Structured Program Delivered by Skilled 52
Home Visitors
Strong Community Ties in a Supportive 55
Agency
Ongoing Funding for Program Permanency 58
CHAPTER 6 CONCLUSIONS, RECOMMENDATIONS, AND AGENCY 62
COMMENTS
Conclusions 62
Matter for Congressional Consideration 66
Recommendations 66
Agency Comments 67
APPENDIXES
APPENDIX I: Description of the Eight Home-Visiting 70
Programs GAO Visited
APPENDIX II: What Happens on a Home Visit? 102
APPENDIX III: Comments from the Department of Education 106
(Could not be reproduced for electronic
viewing)
APPENDIX IV: Comments From the Department of Health and 107
Human Services (Could not be reproduced for
electronic viewing)
APPENDIX V: Major Contributors to this Report 108
TABLES
TABLE 1.1: Early Intervention Saves Money 14
TABLE 2.1: Home Visiting in Nine Western 18
European Countries
7
TABLE 2.2: Federal Programs Used to Fund Home 22
Visitor Projects
TABLE 2.3: Signatories to the FICC Memorandum of 26
Understanding
TABLE 5.1: Characteristics of United States and 48
European Programs GAO Visited
TABLE I.1 Program Profile: Center for Development, 71
Education, and Nutrition (CEDEN)
TABLE I.2 Program Profile: Resource Mothers for 75
Pregnant Teens
TABLE I.3 Program Profile: Roseland/Altgeld Adolescent 79
Parent Project (RAPP)
TABLE I.4 Program Profile: Southern Seven Health 83
Department Program (Parents Too Soon and the
Ounce of Prevention Components)
TABLE I.5 Program Profile: Maternal and Child Health 87
Advocate Program
TABLE I.6 Program Profile: Changing the Configuration 90
of Early Prenatal Care (EPIC)
TABLE I.7 Program Profile: Great Britain's Health 94
Visitor Program
TABLE I.8 Program Profile: Denmark's Infant Health 98
Visitor Program
FIGURES (Could not be reproduced for electronic viewing.)
FIGURE 1.1 Examples of Programs Using Home Visiting 11
to Serve At-Risk Families
FIGURE 3.1: Students Receiving Preschool and Home Visiting 34
Services Were More Successful in Later Years
FIGURE 3.2: Type and Amount of Services Affect Later 36
Reading Ability
FIGURE 5.1 Framework for Designing Home Visitor 49
Services
8
ABBREVIATIONS
-------------
AFDC Aid to Families With Dependent Children
CEDEN Center for Development, Education and Nutrition
EPIC Changing the Configuration of Early Prenatal Care
FICC Federal Interagency Coordinating Council
GAO General Accounting Office
HHS Department of Health and Human Services
MCH Maternal and Child Health
PTS Parents Too Soon
RAPP Roseland/Altgeld Adolescent Parents Program
SPRANS Special Projects of Regional and National
Significance
VISTA Volunteers in Service to America
VNA Visiting Nurses Association, Incorporated
WIC Special Supplemental Food Program for Women,
Infants, and Children
9
CHAPTER 1
---------
INTRODUCTION
------------
For more than a century in both the United States and Europe,
home visitors have provided individuals and families with
preventive and supportive health and social services directly in
their homes. While not a new concept, home visiting is an
evolving service delivery strategy that numerous agencies in the
United States are embracing with renewed enthusiasm, for both
humanitarian and economic reasons. Experts believe that
intervening early in the lives of certain families at risk of
such negative outcomes as low birthweight, child abuse, and
educational failure offers them promise of a better future
through improved health and education. They also believe that
home visiting can break down barriers that prevent families from
accessing the care they need and that preventive services can be
less costly in the long run than providing more expensive crisis,
curative, and remedial services.
But what can home visiting do for those families facing many
interconnected health, social, and educational risks? Is it an
effective strategy for delivering services? What can we learn
from the experience of Europe, where home visiting is a universal
service? The Senate Appropriations Subcommittee on Labor, Health
and Human Services, Education, and Related Agencies, in its
search for innovative strategies to reduce threats to the health
and well-being of disadvantaged families, asked us to answer
these questions.
WHAT IS HOME VISITING?
----------------------
Home visiting is a strategy that delivers health, social support,
or educational services directly to individuals in their homes.
Programs use home visitors of various disciplines and skills to
accomplish various goals and provide various services. For
example, home visiting has been used to deliver nutritional
support to the elderly, medical care to the chronically ill, and
social support to at-risk families. This report focuses on the
home-based services, such as coaching, counseling, teaching, and
referrals to other service providers for additional services,
that are offered as a part of early intervention services for at-
risk families with young children. Programs designed for such
purposes can vary in their goals and services, as shown in figure
1.1.
10
Figure 1.1: Examples of Programs Using Home Visiting To Serve
At-Risk Families
Goals: Improved parenting skills
Enhanced child development
Improved birth outcomes
Services: Information delivery
Referrals to other service providers
Emotional support
Health care
Providers: Nurses
Paraprofessionals
Teachers
Social workers
Home visiting occurs as a delivery strategy in three basic forms.
The first is universal, in which all members of a broad
population receive services. Great Britain uses public health
nurses to provide preventive health information and examinations
directly in the home to all families with newborns, regardless of
family income status or need. The other two strategies target
services to certain families. One offers a limited number of
home visits to assess the environment and family situation, to
provide some basic information, to reinforce positive behaviors,
or to refer the family to other services as needed. The other
targets some families for more intensive services, providing more
frequent home visits over 1 or more years. Home visits may be
part of other program services, which can include center-based
parenting classes and job training classes, and developmental day
care or preschool for children.
SOME FAMILIES FACE SERVICE BARRIERS
-----------------------------------
At-risk families, especially those who are poor, uneducated, or
headed by teenage parents, often face barriers to getting the
health, education, and social services they need. The barriers
can be financial, structural, or personal. Some experts believe
that home visiting can reduce barriers by providing needed
services to these families.
Lack of health insurance, the chief financial barrier, prevents
many at-risk individuals from receiving adequate health care. An
estimated 26 percent of the women of reproductive age--14.6
million--have no health insurance to cover maternity care, and
two-thirds of these--9.5 million--have no health insurance at
all. We reported in 1987#1 that Medicaid#2 recipients and
1Prenatal Care: Medicaid Recipients and Uninsured Women Obtain
Insufficient Care (GAO/HRD-87-137, Sept. 30, 1987).
11
uninsured women received later and less sufficient prenatal care
than privately insured women from the same communities. Women
with no insurance must depend on free or reduced-cost care from a
diminishing number of willing private physicians or from health
department clinics and other settings usually financed by public
funds.
Limited community resources, such as numbers of hospitals,
community health clinics, social service agencies, and individual
providers able or willing to serve the at-risk population, create
structural barriers to care. The Institute of Medicine has
reported that the capacity of clinic systems used by the at-risk
prenatal population is so limited that critically important care
is not always available.#3 Affordable, quality child care for
disadvantaged families is not keeping pace with the growing
numbers of single-parent households. The child welfare system is
hard-pressed to process the large number of children who now need
protection.
Inadequate funding for social and medical support programs
presents an additional structural barrier to the disadvantaged.
Only half of all poor children are covered by Medicaid. Fewer
than half of the 7.5 million individuals eligible for the Special
Supplemental Food Program for Women, Infants, and Children (WIC)
receive the program's nutritional support. Head Start reaches
only 20 percent of the more than 2.5 million eligible low-income
children.
The structure of conventional care providers may be insufficient
to meet the more complex and interrelated needs of the at-risk
family. Experts believe that at-risk families need an array of
services or, at minimum, close coordination among complementary
service providers. A pregnant teen, for example, may need, in
addition to regularly scheduled medical visits, an array of more
comprehensive services, including counseling and basic parenting
instruction. Generally, a mix of related services in one
location or near one another, or adequate linkages among these
services, does not exist for at-risk families.
Personal beliefs, knowledge, and attitudes can present additional
barriers to getting care. Some researchers have found that some
low-income families do not understand or value the need for
preventive services. They may distrust health care providers or
2Medicaid is a federally aided, state-administered medical
assistance program for needy people, authorized under title XIX
of the Social Security Act.
3Institute of Medicine, Prenatal Care: Reaching Mothers,
Reaching Infants, ed. by Sarah S. Brown (Washington, D.C.:
National Academy Press, 1988), pp. 63-69.
12
social workers. These personal barriers are particularly evident
in families experiencing social or cultural isolation resulting
from recent immigration, a lack of friends and relatives that can
provide emotional support, or substance abuse.
Experts view home visiting as one way to bridge some of these
gaps. Providing services to families directly in the home allows
programs to reach out directly to families who may be facing
these barriers. The Office of Technology Assessment, the
National Academy of Sciences' Institute of Medicine, the National
Commission to Prevent Infant Mortality, and various private
organizations and foundations (such as the Pew Charitable Trusts)
suggest that home visiting allows programs to
-- reach parents who lack self-confidence and trust in formal
service providers,
-- obtain a more accurate and direct assessment of the home
environment,
-- link parents with other health and human services, and
-- present a model for good parenting.
Home visitors can support families during major life changes,
such as the birth of a baby. Such personalized support may be
particularly useful for disadvantaged families and families
headed by teens who suffer from isolation and a lack of an intact
social support system.
HOME VISITING AS AN EARLY INTERVENTION STRATEGY
-----------------------------------------------
Home visiting is often used as one means to provide early
intervention services. Early intervention seeks to improve
families' lives and prevent problems before they become
irreversible or extremely costly. For example,
-- prenatal care seeks to promote the health and well-being of
the expectant mother and developing fetus, thereby reducing
poor birth outcomes, such as low birthweight;
-- parenting skills instruction for adolescent mothers with
infant children seeks to promote nurturing skills, thereby
reducing abusive and neglectful behavior; and
-- preschool education seeks to prepare children for learning,
thereby reducing later school failure.
The costs associated with low birthweight, teen motherhood, child
abuse and neglect, and school dropouts are high. The cost to the
nation of low birthweight babies in neonatal intensive care is
13
$1.5 billion annually.#4 The combined Aid to Families With
Dependent Children, Medicaid, and Food Stamps cost in 1988 for
families in which the first birth occurred when the mother was a
teen was estimated at $19.83 billion.#5 The immediate, first-
year public costs of new reported child abuse cases in 1983 were
estimated at $487 million for medical care, special education,
and foster care,#6 and since then the number of child
maltreatment cases reported has gone up by 47 percent. Recent
estimates suggest that each year's high school dropout "class"
will cost the nation more than $240 billion in lost earnings and
forgone taxes.#7
Early intervention can save money. For example, for most
American families, a child's measles inoculation is considered a
standard part of well-child care. But forgoing such
immunizations--which is happening more frequently--has costly
consequences. Lifetime institutional care for a child left
retarded by measles is between $500,000 and $1 million.
Researchers have reported the potential of this and other early
intervention strategies to save money, as shown in table 1.1.
Experts believe that home visiting can be a key mechanism for
reaching families early with the preventive services they need.
Table 1.1: Early Intervention Saves Money
Every $1 spent on: Saves....
------------------ ---------
The federal Childhood $10 in later
Immunization Program medical costs.(1)
Prenatal care $3.38 in later medical costs
for low birthweight infants.(2)
Preschool Education $3-6 in later remedial education,
welfare, and crime control.(3)
4"Special Report: Perinatal Issues 1989," American Hospital
Association, Chicago (1989), p. 2.
5"Teenage Pregnancy and Too-Early Childbearing: Public Costs,
Personal Consequences," Center for Population Options,
Washington, D.C. (1989), p. 3.
6Deborah Daro, Confronting Child Abuse: Research for Effective
Program Design, The Free Press, New York (1988), pp. 155-57.
7Children in Need: Investment Strategies for the Educationally
Disadvantaged, The Committee for Economic Development, New York
(1987), p. 3.
14
Sources:
1. University of North Carolina Child Health Outcomes Project,
Monitoring the Health of America's Children, Sept. 1984.
2. Institute of Medicine, Preventing Low Birthweight
(Washington, D.C.: National Academy Press, 1985).
3. John R. Berrueta-Clement and others, Changed Lives: The
Effects of the Perry Preschool Program on Youths Through Age 19,
Monographs of the High/Scope Educational Research Foundation,
Number 8, The High/Scope Press, 1984.
OBJECTIVES, SCOPE, AND METHODOLOGY
----------------------------------
Our objectives in reporting on home visiting were to determine
-- the scope and nature of existing home-visiting programs in the
United States and Europe that focus on maternal and child
health and well-being;
-- the effectiveness of home visiting as a service delivery
strategy;
-- the factors and strategies critical to designing home visitor
programs; and
-- program and policy options for the Congress and the
Departments of Health and Human Services and Education in
using home visiting as a strategy to improve maternal and
child health and well-being.
To accomplish our first two objectives, we reviewed the
literature on home visiting and interviewed experts in the areas
of medical, social, and education intervention. In reviewing the
literature, we especially looked for research-based evaluations
of home visiting that reported program results and costs. We
used this information, along with site visits to programs in the
United States and Europe that used home visiting as a service
delivery strategy, to accomplish our third objective--developing
a framework of key design characteristics.
We identified and discussed seven key design characteristics with
various home-visiting experts who concurred that these
characteristics were important for developing and operating
effective programs. Through our case studies, we observed these
design characteristics in operation and subsequently combined
these seven elements into four to form the basis for our
framework.
Programs we selected for study were cited, either in the
literature or by experts, as being successful in meeting their
15
objectives. We did not conduct our own evaluation of the
effectiveness or impact of these programs or conduct a
comparative analysis of effectiveness of different service
delivery strategies, such as home-based versus center-based
services. While we identified many service areas that used home
visiting, including home health care for the chronically ill or
the elderly, we focused on programs serving families from the
prenatal period through a child's second birthday.
From a list of 31 programs suggested by experts or the literature
as being successful in meeting their objectives using home
visiting, we conducted standardized telephone interviews to
collect information about program objectives and structure. We
judgmentally selected six U.S. programs to provide diversity
among program characteristics. Primary selection factors
included programs
-- with different objectives,
-- operating in urban and rural areas,
-- with different target populations, and
-- using home visitors with different backgrounds (for example,
nurses, paraprofessionals, lay workers).
In addition, we selected Great Britain and Denmark because of
their long-standing tradition and experience in using home
visitors to deliver maternal and child health services.
At each site we interviewed senior program managers, home
visitors, and their supervisors. We interviewed representatives
of other local service providers at five of six U.S. locations.
In addition, in Great Britain and Denmark, we interviewed
officials from the National Health Service, local health
authorities, Great Britain's Health Visitors Association, and a
Danish member of Parliament. We also accompanied home visitors
on their rounds in the United States, Great Britain, and Denmark.
At the federal level, we contacted officials in the Departments
of Health and Human Services and Education responsible for
programs using home visiting to improve the health and well-being
of mothers and young children. We reviewed agency documents to
identify programs that have funded home visiting.
We did our work between December 1988 and February 1990 in
accordance with generally accepted government auditing standards.
We did not, however, verify program cost information.
16
CHAPTER 2
---------
HOME VISITING IS AN ESTABLISHED
-------------------------------
SERVICE DELIVERY STRATEGY
-------------------------
WITH MULTIPLE OBJECTIVES
------------------------
Home visitors have provided early intervention services in the
United States and Europe for more than 100 years. In Great
Britain and Denmark, home visiting is provided without charge to
almost all families with young children. In the United States,
home visiting is not universally available. It is conducted on a
project-by-project basis, by governmental and private
organizations, primarily targeted to "special needs" families.
Governmental support for home-visiting is split among many
agencies and programs.
The federal government's involvement and interest in home
visiting is apparent from its many programmatic activities,
recently enacted laws, and proposed legislation. Many states are
using project grants and formula funding from recent legislation,
such as Medicaid, to expand home visiting in their states. The
Congress authorized new home-visiting demonstration grants in the
101st Congress, although it did not appropriate funds. Despite
such initiatives, we found only limited information exchange
about home visiting experiences across program lines.
HOME VISITING WIDESPREAD IN EUROPE
----------------------------------
Home visiting is a common part of Western European maternity
care.#8 Home visitors may be midwives, but most often are
specially trained nurses. Usually women are visited at home
after a child's birth (postpartum). Nine European countries
provide prenatal and/or postpartum home visiting either routinely
or for special indications, such as clinic nonattendance. (See
table 2.1.) Seven countries routinely provide at least one
postpartum home visit.
8C. Arden Miller, M.D., Maternal Health and Infant Survival,
National Center for Clinical Infant Programs, Washington, D.C. (1987).
17
Table 2.1: Home Visiting in Nine Western European Countries
Country Prenatal Postpartum
------- -------- ----------
Belgium Xa X
Denmark Xa Xb
Germany O O
Great Britain O X
France O O
Ireland O X
Netherlands X X
Norway O X
Switzerland O X
Legend:
X Home visiting is provided at least once for all pregnant women
or new mothers.
O Home visiting is provided under special circumstances, such as
follow-up for a woman not attending prenatal clinic.
aUnevenly implemented.
bIn municipalities that have home visitors (94 percent of all
Danish municipalities).
Source: C. Arden Miller, M.D., Maternal Health and Infant
Survival.
In the two European countries that we visited, Great Britain and
Denmark, home visiting is a main source of preventive health
information and care for young children. It began, however, as a
way to reduce infant mortality.
Home visiting was begun in Great Britain in 1852 by a local
voluntary group in Manchester and Salford. In 1890, Manchester
became the first locality to employ a home visitor. By 1905, 50
areas employed home visitors. When Great Britain created the
National Health Service in 1948, home visitors were included as a
profession. Today home visitors serve all British families with
young children.
Home visiting in Denmark started as a pilot program in 1932 and
was established by law in 1937. Although the service has always
been optional, nearly every township has a nurse home-visiting
program today. Ninety percent of all Danish infants live in
counties served by home visitors.
Home visiting in Great Britain and Denmark is provided free of
charge as a publicly supported service to families with young
children regardless of family income. It is an established part
of preventive health services in national health care systems to
18
which all citizens have access. Home visitors teach parents good
health practices and provide preventive health services and
medical screenings to infants and children directly in their
homes. In Great Britain, home visitors meet mothers-to-be at the
clinic, and then follow the child after birth--through both in-
home and clinic visits--until the child reaches school age. In
Denmark, home visitors begin visiting the family soon after a
child is born and visit each child several times during the first
year.
Universal home visiting has certain benefits. Such an approach
can attract wider political acceptance with no stigma attached to
receiving the services. In the opinion of public health
officials in Denmark and Great Britain, home visiting promotes
good health practices and has become an important part of
preventive health care in their countries. However, neither
country has a system to evaluate home-visiting program benefits.
Both Great Britain's and Denmark's home-visiting programs are
facing change. Great Britain is reexamining its health service,
with an eye to making it more effective and economical. As a
result, British local health authorities are beginning to develop
local measures of home-visiting effectiveness. Because of a
shortage of home visitors, local health authorities are beginning
to target their services more closely to local needs and to at-
risk families. Health officials believe that in the future, home
visitors will visit each family in home at least once, but
reserve follow-up and more intensive in-home service to families
they deem at risk. Low-risk families will be followed in the
clinic. Denmark is reviewing its health service and may require
each county to make home-visiting services available. However,
Denmark may also begin charging fees for home-visiting services.
U.S. HOME VISITING TARGETED TO LOW-INCOME AND SPECIAL NEEDS
-----------------------------------------------------------
FAMILIES
--------
Home visiting in the United States had a similar beginning to
that in Great Britain and Denmark, but its development has been
much less systematic and uniform. Nevertheless, many local
public and private agencies provide home visiting. Compared to
Europe, U.S. programs that provide home visiting are diverse in
their goals and are likely to be targeted to families with
special needs, such as families with handicapped children or
children not developing normally.
Home visiting began in the United States during the 19th century
to improve the health and welfare of the poor. In 1858, well-to-
do volunteers became "Friendly Visitors" to poor families in
Philadelphia, and the movement later spread to other large
19
Eastern cities. In the early 20th century, settlement houses#9
began to send visiting nurses, teachers, and social workers into
poor families' homes to provide education, preventive health
care, and acute care. This effort was initially fueled by a
growing awareness that prenatal care and proper infant care could
improve the survival of infants. Visiting nurse programs evolved
from these beginnings. During the 1970s, home visiting to
improve low-income children's school readiness was encouraged
through Head Start#10 demonstration projects. Today Head Start,
although primarily a center-based program, administers one of the
largest home-visiting programs for low-income families in the
United States, serving over 35,000 children yearly.
Targeted Programs With Diverse Goals
------------------------------------
Many programs in the United States use home visiting to provide
health, social, or educational services to certain families.
Programs using home visiting are generally targeted to families
with special needs, such as those with developmentally delayed
children or abused children. These programs provide specialized
services depending on the program focus and families' needs.
Very limited data are available to quantify the number of
programs using home visiting. However, two researchers, Richard
Roberts and Barbara Wasik, have recently attempted to develop the
first comprehensive picture of such programs.#11 In 1988, they
surveyed over 4,500 programs in the United States that appeared
to use home visiting as a service delivery technique. Of the
1,900 programs for which they obtained detailed data, 76 percent
were targeted toward families with particular problems, such as
abusive parents or parents with physically handicapped children.
One-third of the programs served children in the 0-3-year-old
range.
Unlike in Europe, where preventive health care is the main
purpose, Roberts and Wasik found that in the United States, many
home-visiting programs focus on education or social services.
Only a third of the programs responding listed health as the
9Community centers established in poor urban neighborhoods where
trained workers tried to improve social conditions by providing
such services as kindergartens and athletic clubs.
10A national program providing comprehensive developmental
services, including educational, health, and social services,
primarily to low-income preschool children age 3 to 5 and their
families.
11Barbara Hanna Wasik and Richard N. Roberts, "Home Visiting
Programs for Low-Income Families," Family Resource Coalition
Report, No. 1 (1989).
20
primary focus. Overall, 43 percent of the responding programs
were either education or Head Start programs.
Only 22 percent of the programs targeted to low-income families
served expectant families before birth and children up to age 3,
compared with 43 percent of programs not specifically targeted to
low-income families. Head Start programs represented 45 percent
of programs targeted specifically to low-income families.
However, Head Start primarily serves children age 3 to 5 years.
FUNDING FOR U.S. HOME VISITING FROM MULTIPLE AGENCIES
-----------------------------------------------------
Federal and state governments support home visiting through many
programs, with both one-time project funds and ongoing funding
sources. We could not determine the full extent of federal
funding for home visiting, because federal managers we
interviewed did not know the extent to which states were using
federal monies to fund home visiting. Federal managers were not
always aware of results of effective programs funded by other
agencies, the materials developed, or of state efforts in home
visiting.
The Departments of Health and Human Services and Education have
provided funds for home visiting to families with young children
through various programs and through both project and formula
grants. (See table 2.2.) Project grants are given directly to
public or private agencies to finance specific projects, such as
developing model programs. Formula grants are given to states,
their subdivisions, or other recipients according to a formula
(usually related to population) for continuing activities not
confined to a specific project. States often have to match
federal formula grant funds with state-contributed funds.
21
Table 2.2: Federal Programs Used to Fund Home Visitor Projects#a
Agency Office Program Type
------ ------ ------- ----
Department of Health and Human Services
---------------------------------------
Office of Head Start Home-Based Project
Human Head Start grant
Development
Services/ Head Start Parent Child Project
Administration Centers grant
for Children,
Youth, and Head Start Comprehensive Project
Families Child grant
Development
Centers
National Center Child Abuse and Formula
on Child Abuse Neglect grant
and Neglect "Challenge"
Grants
National Center Child Abuse and Project
on Child Abuse Neglect Research grant
and Neglect and Demonstration
Grants
Public Maternal Maternal and Formula
Health and Child Child Health grant
Service Health and Services Block
Resources Grant
Development
Maternal Special Projects Project
and Child of Regional and grant
Health and National
Resources Significance
Development (SPRANS)#b
Health Bureau of Medicaid Formula
Care Program grant#c
Financing Operations
Administration
Department of Education
-----------------------
Office of Education of the Formula
Special Handicapped Act grant
Education Part B & H
Programs Programs
22
Chapter 1 Formula
Handicapped grant
Program#d
Handicapped Project
Children's Early grant
Education Program
aHome visiting may be funded by other federal programs not
identified by GAO and not listed here.
bThese projects are funded by a federal set-aside of 10 to 15
percent of the Maternal and Child Health Block Grant
appropriation.
cMedicaid is a joint federal-state program that entitles eligible
persons to covered medical services. The federal government
matches state payments to providers and administrative costs
using a formula based on state per capita income.
dThe Chapter 1 Handicapped Programs of the Education
Consolidation and Improvement Act of 1981 provide grants to
states to expand or improve educational services to handicapped
children.
States have supported home visiting through their use of both
federally funded formula grants and state funds. For example:
-- Tennessee, Michigan, and Delaware have used federal child
abuse and neglect "challenge" grant funds to support home-
visiting programs.
-- Hawaii has used both state funds and Maternal and Child Health
Services (MCH) block grant#12 funds to expand to more sites a
home-visiting program to prevent child abuse and neglect.
-- Missouri has funded a universal, educational home-visiting
program, "Parents as Teachers," using state education funds.
-- Maine is trying to establish public health nurse home visiting
for every newborn, using state public health funds and MCH
block grant funds.
The Departments of Health and Human Services (HHS) and Education
did not know the full amount of federal funds spent for early
intervention services for children who are handicapped,
12The MCH block grant is a federal formula grant awarded annually
to state health agencies to assure access to quality maternal and
child health services, reduce infant mortality and morbidity, and
provide assistance to children needing special health services.
23
developmentally delayed, or at risk of developmental delay.
Also, most federal managers we contacted could not tell us the
amount of funding their programs were providing for home visiting
as an early intervention service delivery for at-risk children.
Managers at the federal level could provide examples of federally
funded demonstration programs that used home visiting, but were
not sure of the extent to which states were using formula grants
to fund home visiting. Clearly, many sources of federal support
for home visiting are available. But overall funding
information is limited. With the exception of Home-Based Head
Start, home visiting has never been the primary focus of any
federal programs.
Despite this federal and state commitment to home visiting, we
found only limited information exchange about home visiting
across program lines. For example, Head Start has developed
materials for home visitors, including The Head Start Home
Visitor Handbook and A Guide for Operating a Home-Based Child
Development Program. However, some program officials in other
HHS agencies were not aware that these guides existed and thus
could not share them with projects they were supervising.
Some federal officials did not know that states were providing
home visiting using federal formula funds. Health Care Financing
Administration officials we contacted who manage the Medicaid
program were not aware that some states were providing preventive
prenatal services in the home as part of the state Medicaid
program.
Some of the clearinghouses funded by federal agencies that have
supported home visiting cannot readily provide information on
that topic. The Education Resources Information Center, a
clearinghouse that the Department of Education supports, was able
to identify resource materials on home visiting. However, two
HHS-funded clearinghouses, the National Maternal and Child
Health Clearinghouse and the Clearinghouse on Child Abuse and
Neglect Information, could not readily identify resource
materials on home visiting to improve maternal and child health
outcomes or to prevent abuse and neglect.
NEW IMPETUS FOR HOME VISITING FROM RECENT LEGISLATION
-----------------------------------------------------
Several recently enacted laws include provisions that may
encourage home visiting. The Education of the Handicapped Act
Amendments of 1986, recent Medicaid prenatal care expansions, and
the 1988 Child Abuse Prevention, Adoption, and Family Services
Act provide options for states to fund home visiting. Recently
introduced bills also contain provisions to encourage home
visiting through earmarked program funds and through additional
Medicaid changes.
24
Public Law 99-457 May Broaden Availability of Home Visiting
-----------------------------------------------------------
The Education of the Handicapped Act Amendments of 1986, Public
Law 99-457, may further encourage home visiting. Through the
addition of Part H, the statute authorized financial assistance
to assist states in developing and implementing statewide,
comprehensive early intervention services for developmentally
delayed and at-risk infants and toddlers and their families. The
legislation extended program benefits to children aged birth
through 2 years in states choosing to participate. The
Department of Education has indicated that home visiting, while
optional, is among the minimum services that should be provided
to eligible children.
States must serve a core group of developmentally delayed
children, but at their discretion can also serve children who are
at risk of developmental delay. Developmental delay includes
delays in one or more of the following areas: cognitive
development, physical development, language and speech
development, psychosocial development, and self-help skills.
Children with a diagnosed physical or mental condition that has
a high probability of resulting in developmental delay are also
eligible. Children can be classed as "at risk" due to either
environmental or biological risk factors. Environmental risk
factors for children could include poverty, having a teen parent,
or being homeless. The legislation gives states flexibility in
defining developmental delay and setting eligibility and service
delivery standards. However, once the standard is set, all
children in the state who are eligible are entitled to services.
State programs must be in place and serving all eligible children
by a state's fifth year of participation, which could be as early
as July 1991 for states that have participated in the program
continuously since its inception in fiscal year 1987.
To help mobilize resources and facilitate state implementation of
Public Law 99-457, agencies within the Department of Education
and HHS created the Federal Interagency Coordinating Council
(FICC). FICC's mission is to develop specific action steps that
promote a coordinated, interagency approach to sharing
information and resources in five areas: (1) regulations, program
guidance, and priorities; (2) parent participation; (3)
identification of children needing services; (4) materials and
resources; and (5) training and technical assistance. (See table
2.3 for participating agencies.) FICC-supported activities
include an annual Partnerships for Progress conference, which has
been used to disseminate information to state officials on
innovative programs as well as on funding sources that can be
used to pay for services. Another joint project was the
development and distribution of a reference book for schools
attended by children who are dependent on medical technology,
such as children who need regular renal dialysis. The Bureau of
Maternal and Child Health and Resources Development and
25
representatives of FICC also sponsored a February 1988 conference
and subsequent publication, Family Support in the Home: Home
Visiting Programs and P.L. 99-457, to provide guidelines and
recommendations for using home visiting as a service delivery
mechanism under the statute.
Table 2.3: Signatories to the FICC Memorandum of Understanding
Signatories
-----------------------------------------------
Department Principal Other
---------- --------- -----
Education Assistant Secretary, Director,
Office of Special Office of Special
Education and Education Programs
Rehabilitative Services
Director,
National Institute
on Disability and
Rehabilitation
Research
HHS Assistant Secretary, Commissioner,
Office of Human Administration for
Development Services Children, Youth and
Families
Commissioner,
Administration on
Developmental
Disabilities
Assistant Secretary Director,
for Health National Institute
on Mental Health
Administrator,
Health Resources and
Services
Administration
Director,
Bureau of Maternal
and Child Health and
Resources
Development
Director,
Office of the
Associate Director
for Maternal and
Child Health
26
Administrator,
Health Care
Financing Administration
States Are Using Medicaid to Fund Home Visiting
-----------------------------------------------
Medicaid has become a more significant source of funding for pre-
and postnatal services as Medicaid eligibility has expanded to
cover more low-income women. Beginning with the Deficit
Reduction Act of 1984, the Congress expanded Medicaid coverage of
pregnant women and children, primarily by severing the link
between eligibility for Medicaid and Aid to Families With
Dependent Children (AFDC).#13 As of April 1, 1990, states are
required to cover pregnant women and children up to age 6 with
family income up to 133 percent of the federal poverty level. At
their option, states can also cover children up to age 8 with
income up to 133 percent of federal poverty and pregnant women
and infants up to age 1 with family income from 133 percent to
185 percent of the federal poverty level.
In states that allow Medicaid payment for home visiting, Medicaid
can serve as an ongoing funding source. The Consolidated Omnibus
Budget Reconciliation Act of 1985 permits states to obtain
federal matching funds when offering more extensive or "enhanced"
prenatal care services to low-income pregnant women. These kinds
of services do not have to be made available to other Medicaid
recipients. States may add case management and extra prenatal
care services by amending their state plans. While home visiting
is not specifically listed as a covered Medicaid service, some
states have used their authority under the 1985 act to obtain
reimbursement for in-home case management services or other in-
home services to certain pregnant women. New Jersey, for
example, requires at least one prenatal and postpartum home visit
for high-risk women being served through its Medicaid-funded
enhanced prenatal care program. According to the National
Governors' Association and the National Commission to Prevent
13Medicaid eligibility for pregnant women and children had been
linked to actual or potential receipt of cash assistance under
the AFDC program or the Supplemental Security Income program. To
be eligible for these programs, income and assets cannot be above
specified levels. On average across the states, a family's
annual income in 1989 had to fall below 48 percent of the federal
poverty level to qualify for AFDC, with income limits ranging
from 14.0 percent ($1,416 for a family of three) in Alabama to
79.0 percent ($7,956) in California. The 1989 federal poverty
level for a family of three was $10,060.
27
Infant Mortality, as of February 1990, 24 states#14 were using
Medicaid to pay pre- and/or postnatal care providers for home
visiting.
Home Visiting Is Encouraged to Prevent Child Abuse and Neglect
--------------------------------------------------------------
The Child Abuse Prevention, Adoption, and Family Services Act of
1988 recognized home visiting as an appropriate strategy for
preventing child abuse and neglect. This act focused federal
efforts to aid states and localities in preventing child abuse as
well as intervening once abuse had occurred. The legislation
reauthorized a state formula grant program that "challenges"
states to establish earmarked funding for child abuse and neglect
prevention programs by providing a 25-percent federal dollar
match. States have used challenge grant monies to support home-
visiting services.
Increased Interest in Home Visiting in Recent Legislative
---------------------------------------------------------
Proposals
---------
Several legislative proposals that addressed home visiting were
introduced in the 101st Congress:
-- The Healthy Birth Act of 1989 (H.R. 1710 and S. 708) proposed
an increased authorization of $100 million to the MCH block
grant program to fund various additional projects, including
home visiting.
-- The Maternal and Child Health Improvement Act of 1989 (H.R.
1584) proposed an increased authorization of $50 million for
the MCH block grant program, to be used partially for home
visiting.
-- The Maternal and Child Health Block Grant Amendments of 1989
(H.R. 2651) proposed an increased authorization of $100
million for the MCH block grant program, with a set-aside to
fund home visiting demonstrations.
-- The Child Investment and Security Act of 1989 (H.R. 1573)
proposed to require Medicaid coverage of prenatal and
postpartum home-visiting services.
-- The Omnibus Budget Reconciliation Act of 1989 (H.R. 2924), The
Infant Mortality Amendments of 1990 (S. 2198), and The
Medicaid Infant Mortality Amendments of 1990 (H.R. 3931)
proposed that prenatal home-visiting services for high-risk
14Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware,
Idaho, Kansas, Maryland, Michigan, Minnesota, Mississippi, New
Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon,
Pennsylvania, Tennessee, Utah, Vermont, Virginia, and Washington.
28
pregnant women and postpartum home-visiting services for high-
risk infants up to age 1 be made optional Medicaid services.
The Congressional Budget Office estimated that if home visiting
was made an optional Medicaid service, as proposed in H.R. 2924,
the additional federal Medicaid cost would be $95 million over a
5-year period for fiscal years 1990-94. If the services were
mandatory, as was proposed in H.R. 1573, the estimated additional
5-year federal cost could go up to $625 million.
None of this legislation was passed as introduced, as of June
1990. However, the Congress did authorize, through the Omnibus
Budget Reconciliation Act of 1989 (Public Law 101-239), new home-
visiting demonstration projects to be funded through a set-aside
from the MCH block grant when its funding level exceeds $600
million (currently at $561 million).
29
CHAPTER 3
---------
HOME-VISITING EVALUATIONS DEMONSTRATE BENEFITS,
-----------------------------------------------
BUT SOME QUESTIONS REMAIN
-------------------------
Evaluations of early intervention programs using home visiting
have shown that children and their families had improved health
and well-being, compared to families who did not receive
services. This was particularly true for families who are among
groups that often face barriers to needed care, such as
adolescent mothers, low-income families, and families living in
rural areas. In a few cases where follow-up studies were done on
programs that combined home and center-based services, these
salutary effects persisted over time as children developed. More
intensive services seemed to produce the strongest effects. But
few experimental research initiatives have compared home visiting
to other strategies for delivering early intervention services.
Cost data, while limited, indicate that providing home-visiting
services for at-risk families can be less costly than paying for
the consequences of the poor outcomes associated with delayed or
no care. Evaluations have also not adequately addressed whether
home visiting is more costly than providing similar services in
other settings.
PROGRAM EVALUATIONS SHOW BENEFITS OF HOME VISITING
--------------------------------------------------
Evaluations of early intervention programs that used home
visiting show that this strategy can be associated with a variety
of improved outcomes for program participants--improved birth
outcomes, better child health, improved child welfare, and
improved development--when compared to similar individuals who
did not receive services. In addition to being at risk for
adverse outcomes, the target population for these programs often
belonged to groups that experience difficulty accessing needed
services.
Examples of improved outcomes associated with home visiting
include the following:
-- Pregnant adolescents in rural areas visited by the South
Carolina Resource Mothers Program had half the percentage of
small-for-gestational-age infants and significantly fewer low
birthweight babies compared to a similar group of pregnant
adolescents in a rural county without such a program.#15
15Henry C. Heins, Jr., and others, "Social Support in Improving
Perinatal Outcome: The Resource Mothers Program," Obstetrics and
Gynecology, Vol. 70, No. 2 (Aug. 1987).
30
-- Low-income mothers visited in Michigan gave birth to babies
with significantly improved birthweight and health at birth,
compared to both their previous pregnancies and to a control
group with similar demographic characteristics.#16
-- Children in working class families randomly assigned to a
group that received home-visiting services had significantly
fewer accidents in their first year and had a better rate of
immunizations than children who were not visited. The home
visiting was more successful when it began prenatally.#17
-- For several home-visiting projects, participants had a lower
reported incidence of child abuse and neglect than that found
in similar families.#18
Children at risk of developmental delay have also benefited from
services delivered through home visiting. Premature low
birthweight babies and malnourished children whose families were
seen by home visitors were able to physically and developmentally
"catch up" to their healthier peers.#19 For example:
-- Fewer low birthweight children in a Florida program needed
additional developmental services after graduating from a
16Jeffrey P. Mayer, "Evaluation of Maternal and Child Health
Community Nursing Services: Application of Two Quasi-Experimental
Designs," Health Action Papers, Vol. 2 (1988).
17Charles P. Larson, "Efficacy of Prenatal and Postpartum Home
Visits on Child Health and Development," Pediatrics, Vol. 66,
No. 2 (Aug. 1980).
18U.S. Congress, Office of Technology Assessment, Healthy
Children: Investing in the Future, OTA-H-345 (Washington, D.C.:
U.S. Government Printing Office, Feb. 1988); Deborah Daro,
Confronting Child Abuse: Research for Effective Program Design,
The Free Press, New York, 1988.
19Tiffany M. Field and others, "Teenage, Lower-Class, Black
Mothers and Their Preterm Infants: An Intervention and
Developmental Follow-up," Child Development, Vol. 51 (1980);
Virginia Rauh and others, "Minimizing Adverse Effects of Low
Birthweight: Four-Year Results of an Early Intervention Program,"
Child Development, Vol. 59, (1988); Gail S. Ross, "Home
Intervention for Premature Infants of Low-Income Families,
"American Journal of Orthopsychiatry, Vol. 54, No. 2 (Apr. 1984).
31
randomly assigned 2-year home-visiting program compared to
children who received no services.#20
-- Three years after the program ended, children in Jamaica who
were home visited to help them overcome the effects of
malnutrition had significantly higher IQ scores than
malnourished children with similar medical and demographic
characteristics who had not received services.#21
Other programs have also found significant improvements in the
cognitive ability of rural and inner-city children who had been
provided with preschool services through home visiting, compared
to children who were not provided with such services.#22
Benefits to Families Can Persist Over Time
------------------------------------------
The full effects of early intervention programs using home
visiting as part of their service delivery can become more
impressive as parents use what they have been taught and children
grow and further develop. Such contact during a child's early
years often results in improved family functioning, better school
performance, and better outcomes after high school. We
identified several programs with longitudinal evaluations that
had provided both center- and home-based services.
From 1962 to 1967, the High/Scope Perry Preschool Program, in
Ypsilanti, Michigan, provided both weekly home visits for the
parents of low-income, 3- and 4-year-olds and comprehensive
center-based preschool services for the children. Children from
the families who agreed to participate were randomly assigned to
either a group that received preschool and home visiting or a
control group. Participants scored significantly higher on tests
of intellectual ability after 1 year in the program and did
better on standardized testing through the middle grades, than
20Michael B. Resnick and others, "Developmental Intervention for
Low Birth Weight Infants: Improved Early Developmental
Outcomes," Pediatrics, Vol. 80, No. 1 (July 1987).
21Sally Grantham-McGregor and others, "Development of Severely
Malnourished Children Who Received Psychosocial Stimulation: Six
Year Follow-up," Pediatrics, Vol. 79, No. 2 (Feb. 1987).
22Donna M. Bryant and Craig T. Ramey, "An Analysis of the
Effectiveness of Early Intervention Programs for Environmentally
At-Risk Children," in The Effectiveness of Early Intervention for
At-Risk and Handicapped Children, ed. Michael J. Guralnick and
Forrest C. Bennett, Academic Press, Inc. Orlando (1987); Charles
W. Burkett, "Effects of Frequency of Home Visits on Achievement
of Preschool Students in a Home-Based Early Childhood Education
Program," Journal of Educational Research, Vol 76, No. 1 (Oct. 1982).
32
did the control children. At age 15, they placed a higher value
on schooling.
For many of these children, early school success served as a
preparation for greater life success. At age 19, young people
who had participated in the program were more likely to be
literate and employed or in college. They were less likely to
have dropped out of school, to be on welfare, or to have been
arrested.#23 (See fig. 3.1.) One reviewer looking at the
effects of preschool pointed to the High/Scope Perry Preschool's
home visiting as being a significant factor in its success.#24
23Lawrence J. Schweinhart and David B. Weikart, "The High/Scope
Perry Preschool Program," in 14 Ounces of Prevention: A Casebook
for Practitioners, Richard H. Price and others, ed., American
Psychological Association, Washington, D.C. (1988).
24Ron Haskins, "Beyond Metaphor: The Efficacy of Early Childhood
Education," American Psychologist, Vol 44, No. 2 (Feb. 1989).
33
Figure 3.1: Students Receiving Preschool and Home-Visiting
Services Were More Successful in Later Years
(Could not be reproduced for electronic viewing.)
Note: Results show comparative outcomes at age 19 for High/Scope
Perry Preschool children compared to the randomly selected
control group.
The Yale Child Welfare Research Program also had impressive
results over time. A group of 17 families received home visiting
along with developmental day care and close pediatric
supervision. The control group, chosen the following year, was
another group of families with similar characteristics who did
not receive program services. Ten years later, more home-visited
families than control group families were employed and had moved
to improved housing. Their children were doing better in school.
Teachers rated the program-participating children as better
34
adapted socially and needing fewer remedial school services than
the control children.#25
Intense Programs Have More Marked Effects
-----------------------------------------
Evaluations of early intervention programs using home visiting
and varying in service intensity--the amount of program contact
with clients over time--found that more intense programs are
generally more effective.
An evaluation of a program in Jamaica that provided home-visiting
services to improve low-income children's cognitive development
found that children who were visited weekly showed the most
marked improvement in development, compared to children who were
randomly assigned to receive less frequent or no services.
Children visited every 2 weeks also showed significant
improvement in cognitive development, but not as great as those
visited weekly. The children visited monthly showed a similar
developmental pattern to the children receiving no services.#26
Intensive home visiting, in conjunction with medical and
educational interventions, has proven effective at keeping IQ
scores of groups of randomly assigned disadvantaged children from
dropping over time, compared to those of control groups. A
comparative evaluation of 17 programs, 11 of which used home
visiting, showed that program effectiveness increased as other
services were combined with home visiting. Two of the three most
effective and most intensive programs used home visiting in
addition to center-based services.#27
The Brookline, Massachusetts, Early Education Project is an
example of home visiting as a crucial service component for
reaching disadvantaged families. This experimental program
randomly assigned recruited families to varying levels of drop-
in, child care, and home-visiting services provided from infancy
through the preschool years. Children of mothers who had not
graduated from college and who received only center-based
25Victoria Seitz and others, "Effects of Family Support
Intervention: A Ten-Year Follow-up," Child Development, Vol. 56
(1985).
26Christine Powell and Sally Grantham-McGregor, "Home Visiting of
Varying Frequency and Child Development," Pediatrics, Vol. 84,
No. 1 (July 1989).
27Donna M. Bryant and Craig T. Ramey, "An Analysis of the
Effectiveness of Early Intervention Programs for Environmentally
At-Risk Children," in The Effectiveness of Early Intervention For
At-Risk and Handicapped Children, Michael J. Guralnick and
Forrest C. Bennett, ed., Academic Press, Inc. (1987).
35
services were almost twice as likely to have reading difficulties
in second grade as similar children who had received both home-
and center-based services.#28 (See fig. 3.2.)
Figure 3.2: Type and Amount of Services Affect Later Reading
Ability
(Could not be reproduced for electronic viewing.)
Source: "The Brookline Early Education Project," Donald E.
Pierson in 14 Ounces of Prevention: A Casebook for
Practitioners, Richard H. Price and others, American
Psychological Association, Washington, D.C. (1988).
28Donald E. Pierson, "The Brookline Early Education Project," in
14 Ounces of Prevention: A Casebook for Practitioners, Richard
H. Price and others, ed., American Psychological Association,
Washington, D.C. (1988).
36
RESEARCH SHOWS HOME VISITING COMPARED TO OTHER STRATEGIES IS
------------------------------------------------------------
PROMISING, BUT MORE STUDY IS NEEDED
-----------------------------------
Whether one early intervention strategy is more effective than
another is difficult to determine from the literature because few
programs were developed and operated as part of a controlled
experiment or quasi-experiment. Many programs demonstrating
benefits to clients delivered both in-home and center-based
services, but did not try to determine which had the greater
impact or which was the most cost-effective. We identified two
comparative studies that examined the differential effects of
early intervention service delivery strategies.
Beginning in 1978, Elmira, New York, was the site of a major and
often-cited research experiment using home visitors as a service
delivery strategy. First-time mothers, particularly teenage,
single, or poor mothers, were recruited for the program and then
randomly assigned to one of four treatments: (1) no program
services during pregnancy, (2) free transportation to prenatal
care and well-baby visits, (3) nurse home visiting during
pregnancy and transportation services, or (4) nurse home visiting
during pregnancy and until the child's second birthday, in
addition to transportation services. The program had both short-
and long-term positive effects for the home-visited mothers and
their children when compared to those receiving only
transportation to health clinics or no services. The positive
effects of those visited in the home, compared to the women who
were not visited, included the following:
-- Higher birthweight babies born to teen mothers and smokers.
-- Fewer kidney infections during pregnancy.
-- Fewer verified cases of child abuse and neglect.
-- Four years later, more months of employment, fewer subsequent
pregnancies, and postponed birth of second child.#29
A primary reason for using home visitors is to reach families who
might otherwise not have access to services, such as rural
families living in isolated areas, or families who might avoid
29David L. Olds and others, "Improving the Delivery of Prenatal
Care and Outcomes of Pregnancy: A Randomized Trial of Nurse Home
Visitation," Pediatrics, Vol. 77, No. 1 (Jan. 1986); David L.
Olds and others, "Preventing Child Abuse and Neglect: A
Randomized Trial of Nurse Home Visitation," Pediatrics, Vol. 78,
No. 1 (July 1986); David L. Olds and others, "Improving the
Life-Course Development of Socially Disadvantaged Mothers: A
Randomized Trial of Nurse Home Visitation," American Journal of
Public Health, Vol. 78, No. 11 (Nov. 1988).
37
formal service providers, such as abusive families. Home-Based
Head Start is an example of a program that provides services
through home visiting predominantly to rural children who could
not take advantage of the traditional center-based Head Start
program. Although the children were not randomly assigned to the
two different service delivery strategies, an evaluation of the
Home-Based Head Start program found that, after statistically
adjusting for initial group differences, children from home-
based, center-based, and mixed home- and center-based Head Start
programs tested equally well in cognitive ability and social
development following their participation in preschool
activities.#30
LIMITED RESEARCH SHOWS HOME VISITING CAN PRODUCE COST SAVINGS
-------------------------------------------------------------
Evaluations that analyze home visiting's costs and benefits,
while few in number, have shown that programs incorporating home
visiting as a service delivery strategy can prevent families from
needing later, more costly public supportive services. Cost
savings become more obvious when examined by longitudinal studies
or when initial costs for alternate solutions are high. Whether
home-based services are more expensive than providing similar
center-based services depends on a program's objectives,
services, and type of provider. Few true cost-effectiveness
studies have been done.
Of the 72 published evaluations we reviewed that identified the
effects of home visiting, only 8 discussed program costs and only
6 had estimates of immediate or future cost savings. Yet the
results of these studies are compelling. They represent
findings from studies with rigorous experimental or quasi-
experimental designs, and several are often cited in the early
intervention literature.
The High/Scope Perry Preschool Program evaluators estimated that
the program--with its critical home-visiting component--saved
from $3 to $6 of public funds for every $1 spent. The total
savings to taxpayers for the program (in constant 1981 dollars
discounted at 3 percent annually) were approximately $28,000 per
program participant.#31 According to the program evaluators,
taxpayers saved approximately $5,000 in special education, $3,000
in crime, and $16,000 in welfare expenditures per participant.
More Perry Preschool graduates enrolled in college or other
advanced training, which added $1,000 per preschool participant's
30John M. Love and others, Study of the Home-Based Option in Head
Start, RMC Research Corporation, 1988.
31Lawrence J. Schweinhart and David B. Weikart, "The High/Scope
Perry Preschool Program," in 14 Ounces of Prevention: A Casebook
for Practitioners.
38
costs; but due to anticipated increased lifetime earnings, the
average preschool participant was expected to pay $5,000 more in
taxes.
The Yale Child Welfare Research Program also showed significant
cost savings over time. Researchers estimated that 15 control
families cost taxpayers $40,000 more in 1982 in welfare and
school remediation expenses than did 15 home-visited families in
a follow-up study conducted 10 years later. Families in the
program showed a slow but steady rise in financial independence,
which translated into reduced subsequent welfare costs. No
significant differences were found for girls, but each
participating boy required, on average, $1,100 less in school
remedial services than boys in families who had not received
services.#32
Few Comparisons of Cost-Effectiveness
-------------------------------------
Cost-effectiveness analysis evaluates the cost of producing a
particular outcome using alternative strategies. But the most
effective or least costly alternative may not always be the most
cost-effective.#33 We found only three cost-effectiveness
analyses of programs that compared home visiting to other
alternatives. In one case, providing home visiting was more
cost-effective than providing longer hospitalization for low
birthweight infants. In another case, using paraprofessional
home visitors in conjunction with professional, center-based
social work therapy was more effective in treating child-abusing
families, but also more costly, than providing center-based
social work therapy alone. A third case showed that providing
home-based preschool services cost slightly less per child on
average than center-based services, but resulted in equal
outcomes.
The New England Journal of Medicine reported that home visiting
allowed one Philadelphia hospital to serve low birthweight
infants more cost-effectively at home than in the hospital. Low
birthweight infants were randomly assigned to one of two groups.
Members of the control group were discharged according to routine
nursery criteria, which included an infant weight of about 4.8
lbs. Those in the experimental group were discharged before
reaching this weight if they met a standard set of conditions.
Families of early-discharge infants received individualized
instruction, counseling, and home visits, and were allowed to
32Victoria Seitz and others, "Effects of Family Support
Intervention: A Ten-Year Follow-up," Child Development.
33Henry M. Levin, Cost-Effectiveness: A Primer, New
Perspectives in Evaluation, Volume 4, Sage Publications (1983).
39
call a hospital-based nurse specialist with any questions for 18
months.#34
Early hospital discharge did not result in later problems, such
as increased rehospitalizations, and proved to be more cost-
effective than keeping infants in the hospital. The average
hospital charge for the early discharge group receiving in-home
services was $47,520 compared to $64,940 for the control group.
The home-visited infants also experienced a 22-percent reduction-
-$5,933 versus $7,649--in physicians' costs. Costs for the nurse
home visits averaged $576 per child, compared to average
additional overall hospital costs and physician charges of
$19,136 per child for the comparison group of low birthweight
infants retained in the hospital. Since 75 percent of the early
discharged infants were on Medicaid, the program represented
considerable public health cost savings.
Another program evaluation studied the cost-effectiveness of
adding home visiting by nonprofessionals to center-based
professional social worker therapy to prevent child abuse and
neglect. Families identified as abusive or potentially abusive
were randomly assigned to either professional social work therapy
services only or a combination of slightly fewer hours of social
work therapy combined with home visiting. No families in either
group were reported for abusing their children while in
treatment. Only 26 percent of the home-visited families dropped
out of treatment during 1 year, compared to 50 percent of the
families receiving center-based services only. Overall, the
home-visited families showed slightly improved outcomes compared
to the group that received only center-based social work
services.#35
However, in this case, combining home visiting with center-based
social work services almost tripled the cost per client (from $93
to $255 per month). The increased costs were due to giving the
home visitors low caseloads (average caseload was 6) and having
a separate supervisor for the home visitors, rather than letting
the social workers supervise home visitors. Program evaluators
suggested that using nonprofessional home visitors could be more
cost-effective if the caseloads were increased, full-time home
visitors were used, and the home visitors were supervised by the
34Dorothy Brooten and others, "A Randomized Clinical Trial of
Early Hospital Discharge and Home Follow-up of Very-Low-Birth-
Weight Infants," New England Journal of Medicine, Vol. 315 (Oct.
9, 1986).
35Joseph P. Hornick and Margaret E. Clarke, "A Cost-
Effectiveness Evaluation of Lay Therapy Treatment for Child
Abusing and High Risk Parents," Child Abuse and Neglect, Vol. 10
(1986).
40
social workers. The evaluation did not analyze long-term costs
or savings, such as the longer term significance of retaining
more abusive or potentially abusive families in treatment.
While some observers might assume that providing home-based
services is likely to be more expensive than providing center-
based services, this is not necessarily so. Head Start officials
told us that Home-Based Head Start cost less per child in fiscal
1988 ($2,429) than did the average 1989 projected Head Start cost
per child ($2,664). However, Head Start provides home-based
services not because they are less expensive, but because they
bring Head Start to rural children living in isolated areas who
might otherwise not have access to a preschool program.
41
CHAPTER 4
---------
POOR PROGRAM DESIGN CAN LIMIT BENEFITS
--------------------------------------
OF HOME VISITING
----------------
Not all programs using home visiting to deliver services have
been successful. Some programs have not measurably improved
maternal and child health, child welfare, and child development.
Program evaluators do not always discuss the reasons for program
failure. But when they do, the reasons are often tied to
specific problems in program design and implementation. By
analyzing the literature on home-visiting evaluations and
consulting with home-visiting experts and program managers, we
identified critical design components that should be considered
when developing programs that use home visitors.
POOR PROGRAM OUTCOMES LINKED TO DESIGN WEAKNESSES
-------------------------------------------------
Some evaluations of programs using home visitors that failed to
achieve desired outcomes have identified certain causes for the
failure. These include
-- failure to use objectives to guide the program and its
services,
-- poorly designed and structured services,
-- insufficient training and supervision of home visitors, and
-- the inability to provide or access the range of services
multiproblem families need because the program is not linked
to other community services.
Several examples illustrate these problem areas.#36
36For additional evaluations of programs that were not
successful at achieving some key objectives, but for which the
causes of failure were not identified or discussed here, see:
Earl Siegel and others, "Hospital and Home Support During
Infancy: Impact on Maternal Attachment, Child Abuse and Neglect,
and Health Care Utilization," Pediatrics, Vol. 66, No. 2 (Aug.
1980); Violet H. Barkauskas, "Effectiveness of Public Health
Nurse Home Visits to Primarous Mothers and Their Infants,"
American Journal of Public Health, Vol. 73, No. 5 (May 1983);
Richard P. Barth and others, "Preventing Child Abuse: An
Experimental Evaluation of the Child Parent Enrichment Project,"
Journal of Primary Prevention, Vol. 8, No. 4 (Summer 1988).
42
Child and Family Resource Program
---------------------------------
The Child and Family Resource Program, a federally funded
demonstration project initiated by the Administration for
Children, Youth, and Families, was an ambitious home-visiting
program that had little impact on one of its two main objectives.
Initiated in 1973, this 11-site, home- and center-based project
was designed to strengthen families economically and socially and
to improve child health and development. Paraprofessional home
visitors helped families access needed social and health
services, including basic education and job readiness training,
and, through child development activities, taught parents to
improve their parenting skills. The program improved mothers'
employment and educational status. However, the program did not
improve child health and development outcomes for the families
randomly assigned to receive program services and only marginally
improved parental teaching skills.
Program evaluators identified three design and implementation
weaknesses that contributed to the program's failure to improve
child health and development. First, home visitors did not pay
sufficient attention to all objectives when providing services;
they spent most of their time counseling on the need for
continued schooling, job training, and employment, instead of
balancing this objective with training for parents aimed at
improving child development. Although child development was a
major program objective, the amount and frequency of child
development services provided were low. Second, the quality of
child development activities provided may have been inadequate.
Home visitors tended not to demonstrate activities so that
parents could learn by imitation. Third, program evaluators
stated that inadequate training and supervision of home visitors
contributed to the program's lack of success.#37
Boston's Healthy Baby Program
-----------------------------
The HHS Inspector General reported in 1989 that Boston's Healthy
Baby Program, an ongoing program, had similar weaknesses. The
program's goal is to improve birth outcomes by preventing
premature birth through health education by home visitors. The
Inspector General did not address program effectiveness or
collect complete data to determine whether program participation
improved birth outcomes. However, the Inspector General reported
37Robert Halpern, "Parent Support and Education for Low-
Income Families: Historical and Current Perspectives," Children
and Youth Services Review, Vol. 10, (1988); Marrit J. Nauta and
Kathryn Hewett, "Studying Complexity: the Case of the Child and
Family Resource Program," in Evaluating Family Programs, Heather
B. Weiss and Francine H. Jacobs, ed., Aldine de Gruyter, New
York (1988).
43
that the program failed to accomplish four of its service
delivery objectives. The program was doing little outreach to
enroll the target population, was not consistently assessing risk
factors among program participants, was providing services late
in pregnancy and not emphasizing all necessary health
information, and was not well coordinated with other programs.
Many of the program's clients contacted by the Inspector General
who had experienced poor birth outcomes, though assessed for
risk, had never received program services or had received them
only postnatally.
The Inspector General attributed these problems to specific
program design and implementation weaknesses. The program's
objectives were not guiding the design and development of
services. The home visitors were poorly trained and supervised.
In addition, the program, serving families with multiple problems
such as inadequate housing and substance abuse, was located in an
agency with little experience in helping such families. The
program staff also had not developed effective linkages with
prenatal care providers and other social service agencies.#38
Rural Alabama Pregnancy and Infant Health Program
-------------------------------------------------
The Rural Alabama Pregnancy and Infant Health Program, one of
five Ford Foundation-sponsored Child Survival/Fair Start
programs, had mixed success in meeting its objectives to improve
birth outcomes, child health, and child development. This
paraprofessional home visitor program improved the use of health
care by low-income families, including adequate immunization of
client children. But it did not significantly improve infant
birthweights, infant health at birth, or infant development,
compared to a demographically similar group of children who were
not visited.#39
Program evaluators in 1988 reported three problems with the
program. First, compared to other Child Survival/Fair Start
programs, the Rural Alabama Program put less emphasis on becoming
familiar with the chosen target population of low-income young
women and their needs. The program was initially designed to
have older, experienced paraprofessional women as home visitors,
but found that younger home visitors could establish closer
relationships and were more effective with young clients.
Second, the program did not have a single structured curriculum
38Office of Inspector General, Department of Health and Human
Services, Evaluation of the Boston Healthy Baby Program (July 1989).
39J.D. Leeper and others, "The Rural Alabama Pregnancy and Infant
Health (RAPIH) Program," presented at the 1988 Annual Meeting of
the American Public Health Association.
44
of information to teach the clients. Finally, program evaluators
concluded that the home visitors needed more supervision.#40
Prenatal/Early Infancy Project
------------------------------
The Prenatal/Early Infancy Project in Elmira, New York,
demonstrated impacts on birthweight, maternal health, reduction
in child abuse, and improved maternal education or employment
status when it was an experimental research program, but when the
local health department took it over, the program was altered.
As a demonstration project, the program had multiple sources of
funding, including HHS, the Robert Wood Johnson Foundation, and
the W. T. Grant Foundation. When the 6-year grant funding ended
in 1983, the local health department absorbed the program, while
changing its definition and extent of services, target
population, and caseload per home visitor. As a result of these
changes, all of the original home visitors left within a few
months. One director of county services told us that the program
was no longer achieving the same reductions in low birthweight as
the original project.
The program's absence of final evaluation data in 1983, reduced
financial support, and location within the local health
department all contributed to the changes. Some of these changes
resulted from a reluctance to invest substantially in a program
whose benefits had not yet been fully demonstrated at that time.
But a difference in philosophy also prompted the change in
program focus. Local officials told us there was not unanimous
agreement with the research program's broad health and social
service orientation and intensity. They also did not agree with
limiting services to the target population of first-time mothers-
-particularly low-income, unmarried teen mothers--even though
these women were among the ones who benefited most from the
experimental program. Local officials believed that some minimum
level of home-visiting services should be provided to a larger
group of pregnant women, which may be diluting the overall impact
of the formerly targeted, high-intensity services.
40Mary Larner, "Lessons from the Child Survival/Fair Start
Home Visiting Programs," presented at the 1988 Annual Meeting of
the American Public Health Association; J.D. Leeper and others,
"The Rural Alabama Pregnancy and Infant Health (RAPIH) Program,"
presented at the 1988 Annual Meeting of the American Public
Health Association; M.C. Nagy and J.D. Leeper, "The Impact of a
Home Visitation Program on Infant Health and Development: The
Rural Alabama Pregnancy and Infant Health Program," presented at
the 1988 Annual Meeting of the American Public Health Association.
45
CRITICAL COMPONENTS FOR PROGRAM DESIGN
--------------------------------------
Our analysis of these and other evaluations, consultation with
experts, and interviews with federal, state, and local program
officials point to the importance of sound program design.
Further, evidence from these sources suggests that certain
program design components are critical to success. Programs
using home visiting as an early intervention strategy can be
successful at achieving their objectives if program designers and
managers recognize the interplay among these critical components.
Information on the success and failure of programs using home
visiting can be found in the education, health, and social
support literature. Yet we could find no cross-discipline
synthesis or analysis of the reasons for these varied outcomes.
While no single approach exists for designing successful
programs, we have identified critical design components with
associated characteristics that appear to be important when
designing and implementing programs that use home visiting as a
service delivery strategy. These key components include
-- clear and realistic objectives with articulated program goals
and expected outcomes,
-- a well-defined target population with identified service
needs,
-- a plan of structured services designed specifically for the
target population,
-- home visitors trained and supervised with the skills best
suited to achieve program objectives,
-- sufficient linkages to other community services to complement
the services that home visitors can provide,
-- systematic evaluation to document program process and
outcomes, and
-- ongoing, long-term funding sources to provide financial
stability.
In operation, these components are not independent of one
another. They must work in harmony, as part of an overall
program design framework. The next chapter describes in more
detail a framework that we developed to guide program design and
management. In addition, we illustrate, through case studies,
how programs with varying objectives, services, and types of home
visitors used these critical components to strengthen program
design and operation.
46
CHAPTER 5
---------
A FRAMEWORK FOR DESIGNING PROGRAMS
----------------------------------
THAT USE HOME VISITING
----------------------
Home visiting evaluators, experts, and managers point to certain
common characteristics among diverse program designs as
prerequisites to achieving program goals. To illustrate how
these characteristics can be used as a framework in designing and
operating programs using home visitors, we reviewed eight
programs operating in the United States and Europe that appeared
to be successful in meeting their stated objectives. (See app. I
for more detailed information on these programs.)
These eight programs commonly used home visitors to deliver
services, yet varied in other ways. They differed in objectives,
in the group they targeted for services, and in the types of
services provided. Some operated in rural areas, others in
urban areas. Some used professionals, such as registered nurses
and social workers, while others used non-college-educated
paraprofessional community women. (See table 5.1 for highlights
of differences.) Despite these differences, these programs
illustrate the importance of certain design characteristics. In
general, these programs' managers
-- developed clear objectives, focusing and managing their
operations accordingly;
-- planned service delivery carefully, matching the home
visitor's skill level to the service provided;
-- worked through an agency with both a health and social support
outlook to provide families with a variety of community
resources either directly or by referral; and
-- developed strategies for ongoing funding to sustain program
benefits over time.
From these characteristics, we developed a framework for
developing and managing programs that use home visiting. The
framework's constituent parts, shown in Figure 5.1, include clear
objectives, structured service delivery procedures, integration
into the local service provider network, and secure funding over
time.
47
Table 5.1: Characteristics of United States and European Programs GAO
Visited
Program Area Population Type of
name served served home visitor#a
------- ------ ----------- ------------
United States
-------------
Resource Mothers Rural Pregnant teens, Paraprofessional
for Pregnant teen mothers
Teens,
South Carolina
Center for Urban Developmentally Professional
Development, delayed children
Education, and
Nutrition
(CEDEN),
Austin, Texas
Changing the Urban Pregnant low- Professional
Configuration income women
of Early
Prenatal Care
(EPIC),
Providence,
Rhode Island
Southern Seven Rural Pregnant teens Professional
Health
Department,
Southern
Illinois
Maternal and Child Urban Pregnant Paraprofessional
Health Advocate women; mothers
Program, with high-risk
Detroit, Michigan newborns
Roseland/Altgeld Urban Pregnant teens; Paraprofessional
Adolescent Parent teen mothers
Project (RAPP),
Chicago, Illinois
Europe
------
Great Britain Nationwide All newborns Professional
Health Visitor
Denmark Infant Nationwide Newborns#b Professional
Health Visitor
48
aProfessional includes individuals with postsecondary degrees in either a
specialized area, such as nursing, or a broader field, such as early
childhood education or social work. Paraprofessional includes individuals
with no postsecondary certification or specialized training.
bAll newborns in municipalities that hire home visitors (90 percent of all
newborns).
Figure 5.1: Framework for Designing Home Visitor Services
Clear Program Objectives
Objectives, clients, and services are interdependent
Objectives as a management tool
Structured Program With Appropriate Home Visitor Skills
Structured service delivery plan
Home visitor skills matched with services
Training and supervision tailored to home visitor needs
Comprehensive Focus With Strong Community Ties
Services linked with other local providers
Agency supports multifaceted approach
Secure Funding Over Time
Plan for program continuity
CLEAR OBJECTIVES AS A CORNERSTONE
---------------------------------
Clear, precise, and realistic objectives are crucial for enabling
programs using home visiting to sustain program focus among the
home visitor staff and to deliver relevant services to an
appropriate client population. Developing such objectives forms
the foundation for determining specific services and identifying
the target population. Well-articulated objectives also allow
programs to develop outcome measures for monitoring progress.
Objectives, Target Populations, and Services Are Interdependent
---------------------------------------------------------------
Objectives, target populations, and services are logically
interconnected program elements. As program managers develop
objectives in response to problems, such as infant mortality or
child abuse, they also begin to identify the client needing help
and the type of services that will suit the client. The Center
for Development, Education, and Nutrition (CEDEN), for example,
developed a program using home visiting to address an expressed
local need. It was created in 1979 in response to a survey of
families in East Austin, Texas, that identified delayed child
49
development as a pressing community problem. To address
children's developmental delays, program managers selected as a
target population children most likely to benefit from program
services--those under age 5, with an emphasis on those under age
2. This selection was based not only on the expressed need of
the community, but also on an assessment of those most likely to
benefit from the proposed services--in this case, very young
children, who are more responsive than older children to measures
for preventing and reducing developmental delay.
Program managers must be realistic in developing objectives and
services. In some instances it may not be possible--or
practical--to meet the needs of all the program's target
population, especially those at highest risk. Roseland/Altgeld
Adolescent Parent Project (RAPP) in Chicago helps pregnant and
parenting teens with parenting skills and self-sufficiency. The
program does not accept certain members of its target group who
have severe problems, such as mental or emotional disorders or
substance abuse. Program officials do not think these women
would benefit from the program because the program services are
not intense enough to help them. RAPP refers women with these
problems to other programs. The program also does not serve
teens who have strong family support and who function well
independently.
In programs that use home visiting, objectives serve as the basis
for determining the frequency of visits and duration of services.
CEDEN, for example, has determined that most children will have
achieved normal or better levels of development after 24 to 34
weekly home visits, so that is the expected length of program
services. The number of visits per child and specific goals and
activities vary, however, according to the child's individual
needs.
Objectives as a Management Tool
-------------------------------
Clear objectives also serve as the basis for determining outcome
measures used in program monitoring and evaluation. For example,
if a program's objective is to reduce the incidence of child
abuse among violence-prone families by teaching appropriate
discipline methods, then comparing the number of reported abuse
incidents among families receiving program services to incidents
among similar families not receiving program services is one
logical measure.
Managers use outcome measures derived from program objectives to
monitor program performance and to make changes. CEDEN examines
information collected from children at entry, mid-program, and
exit on perceptual abilities, fine and gross motor skills,
language skills, and cognitive development to measure progress
toward its objectives of preventing or reversing developmental
delay. It also compares entry and exit statistics for well-child
50
checkups, immunizations, illness and hospitalization rates, and
the number of children with medical coverage to measure progress
toward objectives related to improving the health of program
children.
RAPP also measures progress quarterly by determining whether its
clients receive certain services. For example, to monitor its
objective of increasing well-baby care, RAPP measures the number
of infants getting regular health screening. During the 1989
fiscal year, the program had already exceeded its annual goal of
175 total screenings for all clients by the end of the third
quarter.
Periodic monitoring serves at least two purposes. First and
foremost, it demonstrates whether a program has met its goals.
Second, program objectives, target population, and services can
be modified if needed. The monitoring experiences of CEDEN and
South Carolina Resource Mothers serve to illustrate how
monitoring provides important information to managers.
At the time of our review, preliminary results from an external
evaluation of CEDEN showed that the program was effective in
reducing developmental delays in client children. Further,
CEDEN's executive director said that preliminary results suggest
that the program should
-- emphasize referring both children and mothers to appropriate
health and human service programs,
-- focus on efforts to follow up on families in order to
complete more home visits, and
-- begin to follow up on families no longer in the program to
determine if gains in development are sustained.
South Carolina's Resource Mothers program has been involved in a
number of evaluations. These show that the program has been more
successful at meeting some objectives than others. A 1986
evaluation showed that teens visited by Resource Mothers had
fewer low-birthweight babies than teens in nearby counties who
did not have access to the program. However, a 1989 evaluation
showed that the program has not been as successful in such areas
as encouraging mothers to breast-feed their babies, enroll early
in family planning, and immunize their children at the
appropriate times. The state coordinator said that program
managers will use the evaluation results to determine if any of
the objectives should be changed.
Each of the six U.S. case studies we reviewed had evaluation
components, although they differed in the level of
sophistication. None, however, had completed evaluations that
compared costs to relative benefits. Therefore, program managers
51
could not clearly document the cost savings that each believed
they were achieving.
STRUCTURED PROGRAM DELIVERED BY SKILLED HOME VISITORS
-----------------------------------------------------
A "structured" service delivery approach--one that has defined
activities and a sequenced plan for instruction with a detailed
curriculum or protocol--serves as a blueprint for guiding home
visitor services. The degree of service structure, such as using
written curricula or making a specified number of visits, can
depend upon program objectives and whether professional or
paraprofessional home visitors are used. Programs with multiple
and complex objectives, such as reducing children's developmental
delays, benefit from a plan that details service activities.
Programs delivered by paraprofessional home visitors also
benefit from more planned service activities.
The skills of the provider need to match the services provided.
Programs that deliver technical services, such as medical and
psychological examinations, require highly trained, professional
home visitors. On the other hand, programs that deliver
information and provide referrals to other service agencies do
not need as highly trained home visitors.
Structured Service Delivery
---------------------------
Structuring services with a written curriculum can be
particularly advantageous for programs using home visitors.
Reviews of multiple early intervention program evaluations have
shown that programs using structured interventions and written
curricula were more likely to improve children's development.
Officials of programs we visited said that structured service
delivery
-- promotes the guidance of services by objectives,
-- fosters consistency and accuracy of information provided to
clients, and
-- enables home visitors and their supervisors to systematically
plan future services for clients.
Despite this evidence, one survey of home-visiting programs
indicated that only a third used written curricula.
Four of the six U.S. programs we reviewed used structured
curricula--each one developing its own. The Resource Mothers
program, which uses paraprofessionals, is highly structured. The
program has a detailed set of protocols that describes the
information to be covered during each visit. Generally, each
client receives the same services on the same schedule--tied to
month of pregnancy and age of the baby. The home visitor can
52
deviate from this plan, however, to deal with a client's
particular needs.
The Illinois Southern Seven program, which uses professionals, is
less structured. It provides numerous services--referrals,
emotional support, education on prenatal care and parenting
skills, and well-baby assessments--without structured protocols
to follow during visits. Southern Seven also does not prescribe
the frequency or minimum number of home visits necessary to meet
program objectives. Home visitors decide how many visits are
needed based on a risk assessment done for each client.
Despite variations in the level of service delivery structure,
home visitors, their supervisors, and program managers agreed on
the need to be flexible during the home visit. Responding to a
family's most immediate concerns is important for building a
helping relationship. During one GAO site visit, for example, a
home visitor had planned to work with a child for 1 hour but
instead spent 4 hours helping a family member receive emergency
medical care.
Match Between Program Services and Home Visitor Skills
------------------------------------------------------
The experience of home-visiting experts reinforces what appears
to be intuitively true: programs delivering specialized,
technical services need to use educated and skilled home
visitors. British health visitors, for example, provide hands-on
medical services in the home, such as head-to-toe examinations
of newborns 10 to 14 days old. Because Denmark's and Great
Britain's health-visiting services focus on both preventive
health and secondarily deal with mental, social, and
environmental factors that influence family behavior, these
nurses have medical, social service, and counseling backgrounds.
Austin's CEDEN services are tailored by the home visitors for
each child's diagnosed developmental delay. Home visitors
develop their individualized services by picking from a number
of different activities. The staff are college graduates trained
in a variety of disciplines, including social work, psychology,
and nursing. The executive director affirmed that the home
visitors' independent planning and assessments required this
level of education.
Many services, while not requiring highly skilled professionals
for their effective delivery, do require trained
paraprofessionals. Detroit's Health Advocate home visitors, for
example, teach pregnant clients about proper eating habits,
infant care, problem solving, and birth control. They assist
new clients to meet their basic needs first, since some clients
lack food, clothing, income, or shelter.
53
Training and Supervision Tailored to Home Visitor Skills
--------------------------------------------------------
Programs we visited using paraprofessional home visitors
generally provided more training--both before (preservice) and
after (in-service) home visiting began--than did programs using
professionals. Detroit's Health Advocate program provided a
full-time, preservice, 6-week training course, including such
topics as human development and use of community resources.
Chicago's RAPP provided preservice training entailing a week of
program orientation and a month of supervised, on-the-job
training.
Both programs also provided in-service training. The Health
Advocate's training coordinator regularly discussed in-service
training needs with home visitors and their supervisors. RAPP
paid for external training and encouraged its home visitors
without college degrees to pursue further education.
Programs we visited using highly trained, professional home
visitors tended to provide less direct training. For example,
the Changing the Configuration of Early Prenatal Care (EPIC)
project in Providence, Rhode Island, used nurses from the
Visiting Nurse Association, Inc., with bachelor of science
nursing degrees. Because each nurse home visitor had medical
training, knowledge of community resources, and at least 8 years
of home-visiting experience, the project director did not view
extensive training as a critical program component. Nurses were
oriented to the program but not otherwise trained.
British health visitors require little additional training
because they are extensively trained and credentialed before they
can join a district health authority. Experienced registered
nurses with community nursing experience receive an additional 51
weeks of home visitor classroom and supervised field training.
They are credentialed through a national system before joining
the ranks of the District Health Authority's home health
visitors.
Program officials, managers, and home visitors we contacted--
regardless of program objectives--often talked about the need to
be adequately trained and prepared in a variety of areas in order
to be responsive to their clients' multiple needs. Some spoke
specifically about advantages associated with cross-training--
formal joint training for home visitors of various disciplines---
and the development of a core training curriculum that would be
appropriate for all home visitors. The British health visitor and
home-based Head Start training materials are examples of core
curricula that other programs using home visitors might adopt.
A common personnel component among all home visitor programs was
a stated need for supervision and support. Program officials saw
home visiting as a stressful occupation. Both home visitors and
their supervisors believed that supervisors play a critical role
54
in relieving stress and providing advice on how to work with
clients and handle caseloads. Most of the officials of programs
we visited in the United States that use both professional and
paraprofessional staff agreed that the latter require closer
supervision. The Detroit Health Advocate program experienced
early difficulty with its choice of home visitors--former AFDC
mothers. Program managers and supervisors found that these home
visitors experienced difficulties adjusting to their new
responsibilities and required more support and supervision than
initially anticipated.
Detroit's Health Advocate supervisors accompanied their
paraprofessional home visitors at least once a month, reviewing
each case with the visitor before the next visit. In contrast,
British home visitors are expected to work independently with
little day-to-day supervision. British supervisors have multiple
duties, such as hiring new staff and allocating nursing
resources, and therefore spend limited time on reviewing
individual cases. In Denmark, local health authorities are not
required to hire supervisors for home visitors; in 1986, 69
percent of 277 municipalities had not hired supervisors.
STRONG COMMUNITY TIES IN A SUPPORTIVE AGENCY
--------------------------------------------
Home visitors can help clients overcome some access-to-service
problems by coordinating or providing needed services. In their
coordination role, home visitors act as case managers for their
clients, by locating and helping their clients obtain varied
services from different sources. To do so, home visitors develop
techniques to link clients with various community programs and
service providers. Programs using home visiting benefit from
being located in agencies supportive of and experienced with
providing combined health, social, and educational services to
families.
The success of home visitors in coordinating services for clients
depends largely on the availability and quality of community
resources. In areas where services are limited, home visitors
can help women get access to what care is available. However,
home visiting does not substitute for other needed services, such
as prenatal care.
Linkages With Other Programs
----------------------------
Home visitors need to be familiar with the community's health,
education, and social services network and must develop
relationships with individual providers in order to link clients
with needed community services. Sometimes home visitors
accompany clients to an agency office to help them make initial
contacts with agency staff. They also provide clients with
reference materials listing community resources.
55
Detroit's Health Advocate program developed links to community
resources by participating in provider networks. The program's
managers belonged to a number of local service networks, such as
Michigan Healthy Mothers, Healthy Babies and Detroit/Wayne County
Infant Health Promotion Coalition. The goal of these
organizations was to promote better overall community access to
prenatal care. Health Advocate managers helped organize local
prenatal clinics into a network that met regularly to find ways
to improve access to care.
The CEDEN program also relied on other agencies and
organizations for services to complement its own. CEDEN
maintained a computer-based system of about 200 agencies
offering such services. CEDEN's home visitors learned local
agency procedures so they could help clients complete forms
correctly. Home visitors had specific contacts within the
agencies administering WIC and Medicaid, for example, whom they
could call on to link clients with services. Like the Health
Advocate program managers, CEDEN officials were members of
various committees and councils that addressed the educational,
social services, and medical needs of Travis County (Austin)
residents. These included the Early Childhood Intervention Forum
and the Austin Area Human Services Network.
U.S. program managers we visited that used home visiting said
that it was important to link their programs with other service
providers in the community. Often programs are not designed to
provide comprehensive services, and clients may not know where to
go for help or may need encouragement to go. U.S. program
managers believed this linkage was a critical part of their
programs' success.
In contrast, British and Danish health officials did not believe
that the success of their health-visiting programs is as
dependent on the strength of the local service community. In
Great Britain and Denmark, health visitors work as a part of a
community-based primary health care team consisting of a general
practitioner, a midwife, and a home visitor. As a result, they
do not depend on referrals to coordinate medical care as U.S.
programs do. For other services, however, health visitors
maintain a close working relationship with certain community
support agencies. When British health visitors are confronted
with particular problems, such as child abuse, they report the
family to social services. The family's home visitor meets
monthly with police and social services to coordinate home-
visiting services with social and protective services for the
child.
Location Within Supportive Agency
---------------------------------
Programs that used home visiting often had mixed social, health,
and child development objectives. These programs are enhanced
56
when housed in agencies supportive of the delivery of
multifaceted services. We visited programs with different types
of agency affiliation--administered by a social service agency
within a health department, a university, or an agency
experienced in delivering family services addressing various
problems. All of these agencies were supportive of the programs'
multiple objectives and family-centered approach.
The local health department's division of social services
operates the Southern Seven program. This organizational
arrangement seems to enhance the home-visiting program's ability
to meet both its social support and health-related objectives.
In addition, clients have greater access to the department's
other services, such as prenatal care.
In the Resource Mothers program, each supervisor has a master's
degree in social work and is primarily responsible to the local
health department's social work director. The health department
provides such services needed by Resource Mothers clients as
prenatal care and family planning services. In some locations,
the South Carolina Department of Social Services has an employee
located in the local health department so people can apply for
Medicaid without going to the local Department of Social Services
office.
Catholic Charities' Arts of Living Institute is the parent
organization for RAPP. This private, nonprofit organization
develops and operates programs for pregnant teenagers and
coordinates with other agencies to deliver services that they
cannot directly provide. Since Catholic Charities has expertise
in delivering services related to RAPP's goals, it can advise and
assist RAPP on how to best achieve program goals.
Home Visiting Does Not Substitute For Lack of Services
------------------------------------------------------
Regardless of how well services are coordinated, programs
providing supportive services through home visiting do not
substitute for some gaps in community services. A clear example
is prenatal care. Women who obtain inadequate prenatal care are
less likely to have a healthy birth outcome than women who obtain
adequate care. While the Institute of Medicine recommends that
programs providing prenatal care to high-risk women include home
visiting, it recommends that the first task for policymakers is
making prenatal care more accessible to all.
Programs that use home visiting can help women access what care
is available. Southern Seven officials said prenatal care and
hospital delivery services are inadequate in their rural Illinois
area. No hospital in the 2,000-square-mile area served by the
program provides delivery room services. Only four local doctors
provide prenatal care, and two of them do not participate in
Medicaid. Program officials transport their clients to doctors
57
inside and outside the seven counties to help them obtain needed
care. The nearest hospitals with delivery facilities are in
Missouri and Kentucky, but these states do not accept Illinois
Medicaid. Medicaid beneficiaries therefore have to drive 40 to
60 miles to Carbondale to deliver their babies. Although, for
legal reasons, Southern Seven home visitors are not allowed to
transport women in labor, they make sure such women have
transportation to the hospital by ambulance if no other means
are available.
Southern Seven was the only program we visited that cited such a
serious gap in medical services. The other programs cited other
service gaps, such as inadequate public transportation, mental
health and drug rehabilitation services, child care, and
affordable housing.
ONGOING FUNDING FOR PROGRAM PERMANENCY
--------------------------------------
Developing strategies to secure ongoing funding strengthens
home-visiting services by giving programs time to establish
themselves in the community, build and maintain relationships
with clients and other providers, and maintain steady program
operations. Since it takes time to demonstrate a program's
effect, secure funding gives it an opportunity to do so. But
three of the six U.S. programs we visited were developed as
time-limited projects,#41 without guaranteed sources of
continuing funding. Two of these ceased operation by the end of
1989. The other four programs, however, successfully developed
strategies to maintain services in an uncertain funding
environment.
Time Needed to Implement and Demonstrate Effectiveness
------------------------------------------------------
Developing, implementing, and evaluating the impact of home-
visiting services while maintaining continuity of services takes
several years. Three-year or shorter funding cycles put
considerable pressure on programs to achieve complete
operational status and show some positive effects before ending.
Based on the experience of many programs using home visiting,
experts have concluded that funding insecurity is one of the
basic sources of unpredictability and unevenness in delivering
home-visiting services.
Uncertain funding contributes to operational problems in home-
visiting services. It can result in high turnover which, in
turn, is disruptive to service, increases the need for training,
and contributes to program instability. The Health Advocate
program, for example, had a serious turnover problem, partially
due to its initial way of paying home visitors.
41EPIC, Resource Mothers, Health Advocates.
58
At the beginning, the program's home visitors, who were AFDC
recipients, were given supplementary Volunteers in Service to
America (VISTA)#42 payments instead of becoming regular salaried
employees. When other local health departments established
programs similar to Health Advocates using paraprofessionals,
Health Advocate home visitors moved to these more secure jobs.
None of the 21 original home visitors who started in early 1987
were still visiting clients in August 1989. Consequently, the
program lost clients because some, having established a rapport
with the first home visitor, did not want to continue the
program once "their" home visitor left. The Health Advocate
program had to train additional home visitors to keep an ongoing
staff.
Some U.S. programs we visited needed funding for longer than 3
years if they were to continue services and demonstrate their
effectiveness. Although the first formal Resource Mothers
program evaluation demonstrated that clients had better birth
outcomes, for example, it was not completed until more than 5
years after the initial research program began. By that time,
the original 5-year foundation grant had expired, and the
program was operating through a 3-year federal Special Projects
of Regional and National Significance (SPRANS)#43 grant. Had the
Resource Mothers program not received a second grant, the results
of the original evaluation could not have been used to help
secure further funding.
Providence's EPIC program also received a 3-year federal SPRANS
grant, from October 1986 to September 1989. During those 3 years,
program officials developed, implemented, and completed the
program. They also began but did not complete its evaluation.
They stopped providing program services in June 1989. The
program was planned as a research project to see if nurse home
visiting between weeks 20 and 30 of pregnancy could improve birth
outcomes. Although no immediate state commitment to such funding
was sought, health officials may seek longer term funding to
restart the program if it proves to have been effective. Final
evaluation results were expected by spring of 1990, about 1 year
after program services were terminated.
The Health Advocate program was also a 3-year project that closed
its doors in October 1989 with its evaluation to be completed
later. Program officials were awaiting evaluation results to
42VISTA provides small stipends to full-time volunteers who
work for governmental or nonprofit agencies on projects to
improve the lives of the poor.
43These projects are funded by a federal set-aside of between
10 and 15 percent of the MCH block grant appropriation.
59
determine the impact of the home visits on their clients. In the
meantime, the program has been partially replicated by some
local health departments that saw its benefits and merits, and
program staff have begun a new, community-based maternal and
child health home-visiting effort.
CEDEN, a private, nonprofit organization, has had more stable
funding over its 10-year existence than some of the other
programs. According to the executive director, this has allowed
the program to establish ongoing relationships within the
community, with other service providers, and with clients. CEDEN
is well known and well respected by members of the community and
other area service providers. As a result, many CEDEN clients
are referred from diverse sources--other social service
providers, medical providers, police, family violence programs,
churches, other institutions, and previous clients.
Historically, Great Britain has not had the kind of funding
uncertainty as have some U.S. programs. Since home visiting is
one component of community health services provided by the
National Health Service, it is a firmly established part of the
local community. Home visiting has a long tradition in Great
Britain and is a respected profession. As a result, home
visitors serve as a common point of reference in the community,
sources of standard information, advisors on health, and
overseers of child welfare.
Funding Strategies Needed to Maintain Services
----------------------------------------------
The U.S. programs we visited that were able to maintain
continuous funding of program services followed two strategies.
These entailed developing diverse funding sources, either by
themselves or through sponsoring organizations, and designing
programs to be more closely integrated into the community.
Programs that did not maintain services after initial funding
ended generally depended solely on 3-year research demonstration
grants.
Developing diverse funding sources was one strategy for coping
with funding uncertainty. Home visitor programs have the
potential to tap diverse funding sources because the potential
funding for early intervention is so diversified. CEDEN, a
community-based agency, has obtained, in addition to federal,
state, and local funds, funding from private foundations like
the Ford Foundation and The March of Dimes Birth Defects
Foundation, nongovernmental grants from the United Way and Junior
League, and corporate contributions from IBM and Motorola.
According to CEDEN's executive director, a diverse funding base
prevents the loss of one funding source from disrupting the
program.
60
RAPP and Southern Seven also benefit from diverse funding
sources developed by The Ounce of Prevention Fund, itself a major
funding source. The Ounce of Prevention Fund is a public-private
consortium, with funding from various governmental sources,
foundations, and private sector contributions. Because of such
diverse funding sources, RAPP and Southern Seven program
administrators are freed from having to search independently for
funding. As a result, they can devote their efforts to program
management.
Designing programs to be integrated into the community, thereby
building local support and commitment for the program, is another
strategy that can lead to more stable funding. The Resource
Mothers Program was introduced into rural communities through
town meetings. Community groups involved themselves in finding
and funding local operation sites. The program became an
established part of local community services and was able to
successfully replace demonstration project funding with more
ongoing state-administered funds, such as the MCH block grant
and other state funds.
61
CHAPTER 6
---------
CONCLUSIONS, RECOMMENDATIONS,
-----------------------------
AND AGENCY COMMENTS
-------------------
CONCLUSIONS
-----------
Home visiting is a technique widely used in both the United
States and Europe to provide families with preventive, in-home
services. Home visitors provide a broad range of services,
including home-based assessments, education, emotional support,
referrals to other services, and, in some cases, direct care.
In Great Britain and Denmark, home visiting is part of a
universally available system of health care. Great Britain's and
Denmark's publicly financed, community-based health care systems
offer home-visiting services, without charge, to virtually all
families with young children. In these countries, public health
nurses provide primarily health education and emotional support,
with some developmental assessments and direct care, such as
newborn health checkups.
Home visiting is different in the United States. In contrast to
the European countries we visited, no single federal home-
visiting program or federal focal point for home visiting exists;
rather, the federal government funds home visiting through many
agencies and programs. In the United States, home visiting may
be conducted by professional nurses, social workers, child
development specialists, or paraprofessionals (lay workers).
Home visiting in the United States usually targets families with
specific problems, such as families with handicapped children or
abusive families.
Despite the variations in philosophy and approach, the goals of
home visiting in both the United States and in Europe are
similar: improved child health, welfare, and development. We
believe that home visiting can help families become healthier,
more productive, and self-sufficient, given certain conditions.
Our conclusions about home visiting services in the United States
follow.
-- Home visiting can be an effective strategy for reaching at-
risk families typically targeted by early intervention
programs.
Evaluations of programs that used home visiting have demonstrated
that this strategy can improve the health and well-being of
families and children who often face barriers to care. Clients
of some home-visiting programs have had healthier babies. Home-
visited children have improved in intellectual development.
Projects working with parents likely to abuse or neglect their
children have been able to reduce reported abuse and neglect.
62
Given limited public resources, we believe that home visiting
should be targeted to specific populations most likely to benefit
from these personalized services. These might include young,
poor mothers, particularly single mothers; they have clearly
benefited from past programs. Children who are handicapped,
developmentally delayed, at risk of abuse and neglect or poor
health and development, or live in rural areas also have been
shown to benefit from home-visiting services. One way to target
without stigmatizing the service is to make home visiting
universally available in neighborhoods with high concentrations
of at-risk families.
The public costs associated with problems faced by these
vulnerable children and families are high. While cost data are
limited, evaluations have shown that home visiting can reduce
other costs. But little is known about the cost-effectiveness of
home visiting, compared to other settings or strategies for
providing similar services.
Despite home visiting's potential effectiveness, it is not a
panacea for the problems disadvantaged families face. Home
visiting can help families overcome some of the barriers to care
that they face, such as not understanding the need for preventive
services or not being able to gain access to services on their
own. But home visiting cannot make up for lack of available
community services, such as prenatal care providers, hospital
delivery services, substance abuse treatment services, Head Start
services, or affordable housing. For communities with troubled
populations and limited services, home visiting alone may not be
the appropriate intervention strategy.
-- Successful programs using home visiting share common
characteristics that strengthen program design and
implementation.
The benefits of home visiting depend on certain program design
characteristics. Health, educational, and family support
programs that use home visiting need clear and realistic
objectives. Precise objectives help sustain program focus and
form the basis for determining the most appropriate services for
the needs of a target population, as well as program outcome
measures. Home-delivered services should have well-articulated
and defined activities with a sequenced plan for presentation to
the client. Programs delivering specialized and technical
services in the home, such as well-baby health checkups or
specialized child development services, need more structure and
more educated, skilled visitors than programs delivering
information, support, and referrals to other providers. Home
visitors need solid pre- and in-service training and close
supervision from professionals. This program support is
63
particularly important for paraprofessionals, but professionals
also benefit from supportive supervision and training.
We believe that no single "best" home-visiting model or approach
exists. Home visiting can take a variety of forms--varying in
terms of who provides the services (professional or
paraprofessional), what services they provide (hands-on services
or referrals to other providers), and how frequently services are
provided (single assessment visits or sustained visiting over 1
or more years)--depending on the objectives, target population,
and expected outcomes. The critical point is to match objectives
and services to the target population's needs and to the home
visitors' skills and abilities.
To have sustained impact, programs using home visiting need to
develop strategies for securing ongoing funding and become
permanent institutions within the community. Ongoing funding
sources provide financial stability and increase a program's
longevity, community acceptance, and client participation.
Medicaid is one such source of ongoing funding. State funding,
such as support for handicapped education, is another. To become
a more permanent part of the local service structure, programs
using home visiting need to be located within agencies or
departments that can be supportive of interdisciplinary programs
that offer both health and social services and are willing to
make a commitment to ongoing service delivery. Programs using
home visiting need to link closely with other community services,
to help home visitors be effective case managers.
-- The federal government's commitment to home visiting can be
better coordinated and focused.
Both the Congress and executive agencies appear to agree that
home visiting can be a viable service delivery strategy, and have
provided funding through numerous agencies and programs. The
federal government, however, needs to better focus and coordinate
its efforts to improve program design and operation. The
government should also play a greater role in communicating
program successes and lessons learned from perceived failures, to
adequately design, implement, and evaluate programs. We believe
this can be done through existing resources and mechanisms.
The Congress has indicated its interest in home visiting in
recent legislation. The Omnibus Budget Reconciliation Act of
1989 authorized a new federal set-aside from the MCH block grant
for maternal and infant home-visiting demonstration programs,
among other projects. Funds will become available when the block
grant appropriation exceeds $600 million (currently at $561
million). Twenty-four states have used the Congress' recent
Medicaid expansions to offer home visiting as part of Medicaid-
covered enhanced prenatal and/or postnatal care services. Home
visiting is not, however, a specific Medicaid-covered service.
64
The Congress considered making home visiting an explicitly
covered service for high-risk pregnant women and infants in the
last session, but the proposal did not survive reconciliation.
The Congressional Budget Office has estimated that the additional
federal costs of amending the Medicaid statute to explicitly
cover home visiting for high risk pregnant women and infants when
prescribed by a physician would range from $95 million for fiscal
years 1990-94 if home visiting was an optional service to $625
million if mandatory.
HHS and the Department of Education have mechanisms for
collaborating with states and localities and helping them develop
programs for providing early intervention services to children.
The Federal Interagency Coordinating Council is one mechanism for
sharing information at the federal level on successful service
approaches and for cooperating on joint projects. It has already
been involved in one national conference on home visiting. With
its emphasis on interagency and intergovernmental collaboration
for family support programs, FICC appears to be a ready focal
point for further home-visiting initiatives, especially
information exchange. Other federal mechanisms that can support
home visiting include existing clearinghouses and technical
assistance to states, localities, and providers to help them
initiate home-visiting services or to improve current services.
One area that needs focus is training and service curricula.
Programs that we visited often developed their own curricula.
Programs could benefit from existing materials, such as The Head
Start Home Visitor Handbook. Federal agencies that fund home
visitors could pool resources to develop comprehensive training
curricula, training materials, and visiting protocols that local
programs could use or adapt. Well-developed training and
visiting protocols would both improve home-visiting practices and
decrease the start-up time and costs for new programs.
Federal demonstration projects could be better focused to improve
program practice and fill information voids. This might include
stepped-up federal efforts to encourage the integration of home
visiting into existing community service networks where
particular program approaches have proven to be effective or to
require grantees to develop concurrent or subsequent funding
streams in order to continue services after the demonstration
period. Federal demonstrations need to focus on evaluating the
costs and future cost savings associated with home visiting, not
just the efficacy of alternate service delivery strategies.
Finally, federal program managers need to encourage the
replication of proven, effective program designs in other
communities.
65
MATTER FOR CONGRESSIONAL CONSIDERATION
--------------------------------------
The Congress has expressed its interest in home visiting as a
strategy for bolstering at-risk families. In view of the
demonstrated benefits and cost savings associated with home
visiting, the Congress should consider establishing a new
optional Medicaid benefit: as prescribed by a physician or other
Medicaid-qualified provider, prenatal and postpartum home-
visiting services for high-risk women, and home-visiting services
for high-risk infants at least up to age 1. Making home
visiting an explicitly covered Medicaid service to improve birth
outcomes will encourage states to provide ongoing funding for
prenatal and postpartum home visiting.
RECOMMENDATIONS
---------------
We recommend that the Secretaries of HHS and Education require
federally funded programs that use home visiting to incorporate
the following program design elements:
-- clear objectives, which are used to manage program progress
and to evaluate program outcomes;
-- structured services by trained and supervised home visitors
whose skills match the services they deliver;
-- close linkages to other service organizations to facilitate
access to needed services; and
-- commitments for further funding beyond any federal
demonstration period to sustain benefits beyond short-term
initiatives.
More specifically, the Secretary of HHS should incorporate these
program design components when implementing provisions of the
Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239)
pertaining to new home-visiting demonstration projects.
We further recommend that the Secretaries of HHS and Education:
-- make materials on home visiting more widely available through
established clearinghouses, conferences, and communications
with states and grantees.
-- provide technical or other assistance to programs to more
systematically evaluate the costs, benefits, and future cost
savings associated with home-visiting services.
-- give priority to collaborative, interagency demonstration
projects designed to (1) meet the multiple needs of target
populations, (2) incorporate home visiting permanently into
local maternal and child health and welfare service systems,
and (3) replicate models that have demonstrated their
efficacy.
66
-- charge the Federal Interagency Coordinating Council with the
federal leadership role in coordinating and assisting home-
visiting initiatives through such activities as (1) providing
technical assistance in developing program services and
program evaluations and (2) supporting the development of a
core curriculum for home-visitor training.
AGENCY COMMENTS
---------------
HHS and the Department of Education generally concurred with our
conclusions and recommendations. They supported our
characterization of home visiting as a strategy to provide early
intervention services to certain targeted populations, and not a
stand-alone program. The departments agreed with the need to
more systematically evaluate programs incorporating home-visiting
services and provided examples of cost evaluation studies in
process. These cost studies may help fill some of the current
knowledge voids, provided their results are well publicized and
easily accessible. They also indicated they will attempt to make
home-visiting materials more widely available through existing
mechanisms, such as established clearinghouses.
Both departments recognized the merit of the design elements that
we recommended be incorporated into programs that use home
visiting. HHS stated it will apply them to home-visiting
services provided through the MCH block grant and will consider
their applicability to other departmental programs. Although
Education provided examples where some of the design elements are
already incorporated as program funding criteria, the department
believes that more systematic research is needed to identify
which variables are causally related to specific outcomes and
suggested that the efficacy of these components be verified
through research rather than requiring that they be included in
every program funded.
We believe that these program design elements--developed through
an extensive literature review, consultation with experts, and
case study analyses--reflect sound management principles that
should be considered when designing and managing programs that
incorporate home visiting. For this reason, we do not believe
additional research is needed to demonstrate the causal link
between these general design elements and overall program
success. But we agree that identifying the relative
effectiveness of variations within these design elements--such as
the optimal type of home visitor considering stated goals and
target populations or the nature and intensity of services--may
warrant further research and evaluation.
Both HHS and Education agreed with our recommendation to give
priority to federal demonstration projects that meet the multiple
needs of target populations and replicate models of proven
67
efficacy. But both were hesitant to give priority to home
visiting over other early intervention approaches or settings, in
the absence of conclusive evidence of its relative effectiveness.
We agree that priority should not necessarily be given to home
visiting over other effective approaches. Our intent was to
emphasize the importance of integrating effective services into
existing local-level service delivery systems on a continuing and
sustained basis, rather than continuing to fund short-term,
finite, experimental research and demonstration projects with
little lasting community value.
HHS did not fully concur that FICC should have the federal
leadership role in coordinating and assisting home-visiting
initiatives, believing this to be somewhat beyond FICC's stated
mission of serving handicapped children. As discussed on earlier
pages, FICC has already conducted high-profile activities related
to home visiting and appears to be an established interagency
mechanism that could facilitate the federal government's
involvement with home-visiting activities. This role appears to
fit within FICC's stated goal of developing action steps that
promote a coordinated, interagency approach to sharing
information and resources, especially materials, resources,
training, and technical assistance to agencies and states serving
children eligible for services under Public Law 99-457.
HHS did not agree that amending the Medicaid statute to cover
home visiting as an optional service was necessary. It pointed
out, as did we, that states essentially have that option, since
some types of home visiting are presently covered under different
categories of service. But we believe that explicitly making
home visiting an optional covered service would send a clear
message to the states about the efficacy of home visiting as a
preventive service delivery strategy and would encourage its use,
particularly for high-risk pregnant women and infants.
Finally, HHS commented on the scope of our review. HHS believed
we did not adequately address the different contexts in which
U.S. and European programs using home visiting operate. In
chapters 2 and 6, we characterized these different operating
environments, especially noting Great Britain's and Denmark's
systems of universal, publicly financed, community-based
services, available to all regardless of family income. But
rather than focusing on such contextual differences between
Europe and the United States, we used the case studies to analyze
the commonalities in the content and methods of delivering
services in the home, which were similar in many respects in all
locations visited.
HHS also suggested that a more thorough discussion of the pros
and cons of building home-visiting programs around public health
nursing would have been helpful. We agree that this approach may
have merit for some communities and some objectives. But the
68
public health nurse is only one model of home visiting; its focus
on public health services delivered by professional nurses may be
ill suited for other early intervention programs with differing
objectives. The key, as Education commented, is that states and
local providers should have the flexibility to decide which
mechanisms and settings are appropriate to meet the individual
needs of the children they serve in their communities.
We have incorporated the departments' technical comments into our
report where appropriate.
69
APPENDIX I APPENDIX I
DESCRIPTION OF THE EIGHT HOME-
------------------------------
VISITING PROGRAMS GAO VISITED
-----------------------------
This appendix provides programmatic and administrative details
about the eight home-visiting programs GAO visited in the United
States and Europe. The programs are presented in order of length
of existence, with the U.S. programs first. Each description
includes the following:
-- A background section, which highlights the history of the
program, its goals and objectives, and the target population.
-- A services and activities section, which describes the
services provided in the home and the type of service
provider.
-- A results section, which describes evaluation efforts and
results.
-- A section describing the program's funding, costs, and
benefits.
-- A section describing officials' views about the program's
future.
70
APPENDIX I APPENDIX I
CENTER FOR DEVELOPMENT, EDUCATION, AND NUTRITION
------------------------------------------------
Table I.1: Program Profile: Center for Development, Education,
and Nutrition (CEDEN)
Geographical areas served: Austin and Travis County,
Texas
Goals/objectives: Prevent/reverse
developmental delay;
promote family self-
sufficiency
Administrative agency: Private, nonprofit
Service delivery method: Home visiting, group
meetings
Target population: Developmentally delayed
children up to 60 months
of age and their families
Number and timing of intervention: 24-34 consecutive weekly
visits after enrolling
Home visitor qualifications: College degree, 3 years'
experience in child
development preferred
Supervisory characteristics: College degree, home
visitor experience
Number of home visitors: 6
Clients served: 250 children in 1988
Fiscal year 1989 funding: $441,134
Evaluation results: Improvement in mental and
physical development,
health, parent-child
interaction, and home
environment
Background
----------
The Center for Development, Education, and Nutrition, founded in
Austin, Texas, in 1979, is a private, nonprofit research and
development center that provides educational and human services
to children with developmental deficiencies and to their parents.
71
APPENDIX I APPENDIX I
CEDEN's primary goals are to (1) prevent or reverse developmental
delay in children, thereby promoting and strengthening their
intellectual, physical, social, and emotional development; (2)
help their parents to plan for, achieve, and maintain self-
sufficiency; (3) improve or maintain an acceptable home
environment; (4) improve or maintain the health care and
nutritional status of program children; and (5) improve parent-
child interaction.
CEDEN's founder and executive director conducted a needs
assessment of low-income families in East Austin, home to many of
the city's poorest Hispanic families. From this, she ascertained
that their highest priority of stated needs was for services to
improve child and family development. CEDEN originally served
primarily low-income Hispanic children and women who lived in the
Hispanic areas of Austin. Over the years, it expanded its
target population to include all ethnic and cultural backgrounds
and all of Travis County, Texas, which includes the city of
Austin.
CEDEN targets infants and young children up to 60 months of age
who are either developmentally delayed or at high risk for being
so, due to biological or environmental circumstances. Infants
and young children up to 24 months of age receive priority
because research indicates that children who are developmentally
delayed should be reached by age 3.
CEDEN is governed by a 20-member board of directors. The
executive director is responsible for overall management and
administration. A program coordinator oversees service delivery
and supervises the six home visitors, referred to as home parent
educators.
Program Services and Activities
-------------------------------
Services are delivered through three programs: (1) the Parent-
Child Program, which focuses on improving infant and child
development; (2) the Pro-Family Program, which concentrates on
teaching parenting skills and developing support groups; and (3)
the Family Advocacy Program, which helps needy families to become
self-sufficient. Most services are delivered through the Parent-
Child Program, while the other two programs complement it by
ensuring that the family's basic needs, such as food, shelter,
and clothing, are met.
Home visiting, along with monthly group meetings, is the primary
service delivery method for Parent-Child Program services. The
home parent educators must have college degrees, preferably have
3 years' experience in child development, and are expected to
establish a rapport with their clients. They receive 2 weeks of
72
APPENDIX I APPENDIX I
preservice classroom training and 1 month of on-the-job training.
Some of the topics covered include case assessment, planning, and
reporting. They also receive in-service training about every 2
weeks. The training, which lasts from 30 minutes to 4 hours,
covers various subjects, such as stress management, health
education, child abuse, and alcoholism. Their supervisor, the
program coordinator, has an educational background in language,
child development, and psychology.
After enrolling in the program, each family receives 24 to 34
consecutive weekly home visits. Before beginning these visits,
the CEDEN staff and the family prepare an individual development
plan for the child and for the family.
CEDEN has an Infant Stimulation Curriculum, which describes
various activities for each area of child development. Other
services include providing health and nutrition information and
nutritional and diet analyses, improving the home environment,
and making health and related social service referrals. The home
parent educators use the curriculum, the results of preentry and
mid-program tests, and the individual and family development
plans to plan each visit. They use a structured approach to
ensure that the program's goal and objectives are achieved.
However, the program is flexible because the family's needs will
determine which services are provided and which infant
stimulation and child development activities will be used.
During the home visit, the home parent educator asks children to
perform certain activities, depending on their developmental
needs. She also encourages the parents to interact in a
prescribed manner with their children in order to maintain the
progress made through participation in the program. In addition,
she may refer the family for medical and social services, an
important program component.
Program Results
---------------
CEDEN collects and compares specific information for all program
clients as well as a nonequivalent control group. The outcome
measures relate to mental and physical development, health,
parent-child interaction and home stimulation, and the home
environment. Based on program evaluations, the program has
helped clients in all the measured areas. For example, at
program entry, 45 percent of the infants have cognitive and motor
development delays. During each program year, this has been
reduced to 15 percent or less. At entry, 20 percent of the
houses are unclean, 21 percent are unsafe, and 26 percent are
dark and depressing. At exit, 69 percent of the families
improved their home environment in one or more of these areas.
73
APPENDIX I APPENDIX I
Program Funding, Costs, and Benefits
------------------------------------
During 1989, CEDEN received about $441,000 from several sources,
including about $255,000 from federal, state, and local
governments; $58,000 from nongovernmental grants; and $101,000
from foundations. The cost of an average CEDEN home intervention
in 1984-85, the most current year for which information was
available, was about $1,095 per client.
Program officials have not conducted a cost-effectiveness
evaluation for their primary goal of preventing or reversing
developmental delay. However, program officials believe that in
the long run, the need for and therefore the cost of special
education for children will be reduced through the prevention and
reversal of developmental delay.
Program Outlook
---------------
CEDEN operated with about $85,000 less in 1989 than in 1988.
However, due to CEDEN's diverse funding base, this loss did not
have a major impact on services. The executive director is
applying for several more grants and, based on past experience,
is confident that the program will receive additional funding.
In 1988, CEDEN served about 250 children of an estimated 3,900
to 4,900 target population. The executive director would like
to hire additional home parent educators to serve more families.
74
APPENDIX I APPENDIX I
RESOURCE MOTHERS FOR PREGNANT TEENS
-----------------------------------
Table I.2: Program Profile: Resource Mothers for Pregnant Teens
Geographical areas served: 16 rural counties in
South Carolina
Goals/objectives: Reduce infant mortality
and low birthweight
Administrative agency: State and local health
departments
Service delivery method: Home visiting
Target population: Pregnant teens and teen
mothers
Number and timing of intervention: Monthly 1-hour prenatal
visits; 1-hour bimonthly
postnatal visit up to age
one
Home visitor qualifications: High school diploma;
ability to establish a
rapport
Supervisory characteristics: Master's degree in social
work
Number of home visitors: 16
Clients served: Over 1,300 from July 1986
through February 1988
Fiscal year 1989 funding: $521,351
Evaluation results: Reduced the number of low
birthweight babies;
increased the receipt of
prenatal care
Background
----------
The South Carolina Resource Mothers for Pregnant Teens program
was developed in 1980 to deal with the state's high infant
mortality rate, among the nation's highest for the past several
years. The program's goal is to reduce the mortality and
morbidity of infants born to adolescents and to improve the
health and parenting activities of those adolescents. The
75
APPENDIX I APPENDIX I
program initially targeted teenagers 17 years of age and under,
pregnant with their first baby. The program now serves 18-year-
olds and teens who have had more than one child. The teens must
live in 1 of 16 rural counties that program officials have
identified as having pregnancy rates and poor birth outcomes for
teenagers that exceed the state's rates. The program targeted
teenagers because they have a higher percentage of low
birthweight infants.
The Resource Mothers program was developed under the direction of
the Bureau of Maternal and Child Health within the South
Carolina Department of Health and Environmental Control and a
licensed clinical psychologist. They decided that the program
would address the social, educational, and health needs of the
teens, and that services would be delivered through home visits
and referrals to other agencies. The home visitors, referred to
as Resource Mothers, would be women from the same community in
which the teens lived, primarily because they believed teens
would open up to them more readily than to a social worker or
nurse.
Originally, the program was a research project jointly managed by
the Medical University of South Carolina, McLeod Regional Medical
Center, Pee Dee Health Education Center, and the Pee Dee 1 Health
District. The Bureau of Maternal and Child Health began
administering the program in 1985.
The state coordinator for the Resource Mothers program has
primary responsibility for administering it. The district
coordinators, one in each of the four health districts in which
the program operates, administer the program at the local level.
They supervise the 16 resource mothers and report to the state
coordinator. The district coordinators and resource mothers are
employees of the local health department operated by the
Department of Health and Environmental Control.
Program Services and Activities
-------------------------------
The Resource Mothers program has many objectives that address
the program's goals of decreasing infant mortality and improving
health and parenting activities of adolescents. These
objectives cover many medical, social, and educational outcomes
that can affect low birthweight, the baby's health, and the
teen's future. They include, among others, early entry into
prenatal care, gaining the recommended amount of weight during
pregnancy, age-appropriate infant clinical visits and
immunizations, developing parenting skills, family planning, and
entry into job training. The primary service delivery strategy
is home visits made by resource mothers.
76
APPENDIX I APPENDIX I
The resource mothers fulfill five roles: teacher, facilitator,
role model, reinforcer, and friend. They are women from the
local community who have high school degrees and an ability to
establish rapport with teens. The first resource mothers
received 6 weeks of preservice training; those hired when the
program expanded received 3 weeks. The training covered several
subjects, including stages in a pregnancy, proper nutrition,
labor and delivery, parenting skills, home-visiting techniques,
and the local service provider network, as well as going on some
home visits. New resource mothers are trained by the district
coordinators, who have master's degrees in social work. All
resource mothers receive in-service training at the state and
local level covering various topics, such as domestic violence
and stress management.
The home visits are highly structured, with specific goals and
learning objectives for each visit, depending on the month of
pregnancy or the infant's age. The resource mothers, however,
have flexibility to deal with each teen's particular needs during
each visit. Services are offered beginning in the first
trimester of pregnancy, although not all teens enter the program
at that point. The resource mothers visit each teen at least
monthly during pregnancy, daily in the hospital after delivery,
and every 2 months during the baby's first year of life.
During pregnancy, the resource mothers emphasize the need for
early and regular prenatal care and for preventing or reducing
certain risk factors, including smoking, alcohol or drug use, and
poor nutrition. After delivery, they emphasize appropriate
infant feeding, immunizations, and well-child visits, and teach
and reinforce positive parenting skills. The resource mothers
also refer the teens to other service providers to ensure that
their medical and social needs, such as adequate food and
housing, are met, and they reinforce what the teens are told by
their health care providers.
Program Results
---------------
Based on an evaluation by Dr. Henry C. Heins and others, the
program has positively affected the incidence of low birthweight
among teens and increased the number of teens receiving adequate
prenatal care. Completed in 1986, the study compared teens who
received visits from resource mothers to teens who did not, and
showed that 10.6 percent of the visited teens had low birthweight
babies compared to 16.3 percent of nonvisited teens, and 82
percent of visited teens received adequate prenatal care compared
to 64 percent of nonvisited teens. The program was being
evaluated again during our visit, but results were not
available.
77
APPENDIX I APPENDIX I
A second evaluation, conducted by the South Carolina Bureau of
Maternal and Child Health, showed that the program met its
objectives of 50 percent of the teens enrolling in school or job
training and 80 percent not becoming pregnant for 1 year after
giving birth. The program did not meet its objectives of 85
percent of the teens gaining the recommended weight during
pregnancy, 90 percent enrolling in family planning clinics, 16
percent breast-feeding their babies, and 90 percent of the
infants receiving age-appropriate clinical visits and
immunizations. Because of data collection difficulties, program
officials were unable to determine if the program met its
objectives related to parenting skills, reducing health risks,
and increasing knowledge about health behaviors.
Program Funding, Costs, and Benefits
------------------------------------
The program was originally funded by a Robert Wood Johnson
Foundation grant awarded to the Medical University of South
Carolina. When the state began administering the program in
1985, the program was funded by a 3-year federal Special Projects
of Regional and National Significance grant, and in fiscal year
1987, the state added some state funds to the program. During
fiscal year 1989, the program received $167,998 in state funds
and $353,353 in federal MCH block grant funds.
During the same year, the estimated cost for one resource mother
was $15,715, which included salary, fringe benefits, and
transportation. In 1987, the cost of supporting one low
birthweight infant in a neonatal intensive care unit was $13,616.
Since program evaluations show that teens visited by Resource
Mothers have fewer low birthweight babies, program benefits
exceeded program costs.
Program Outlook
---------------
The Resource Mothers program is currently funded with state and
MCH block grant funds. State officials are exploring the use of
Medicaid funds as well. Program officials are confident the
state legislature will continue to support this program because
there is strong evidence that it makes a difference. The program
will continue to operate in the same 16 rural counties, and
program officials think that the program will eventually operate
statewide.
78
APPENDIX I APPENDIX I
ROSELAND/ALTGELD ADOLESCENT PARENT PROJECT
------------------------------------------
Table I.3: Program Profile: Roseland/Altgeld Adolescent Parent
Project (RAPP)
Geographical areas served: Roseland and Altgeld
communities, Chicago
Goals/objectives: Decrease negative
outcomes associated with
teen pregnancy; decrease
potential infant
mortality and morbidity;
and increase healthy
family functioning
Administrative agency: Catholic Charities' Arts
of Living Institute
Service delivery method: Home visiting and group
support meetings
Target population: Teen and pregnant mothers
age 11-20
Number and timing of intervention: One prenatal visit;
weekly until baby is 3
months old
Home visitor qualifications: Bachelor's degree
preferred but not
required
Supervisory characteristics: Master's degree preferred
but not required
Number of home visitors: 5
Clients served: 160-175 per year
Fiscal year 1988 funding: $327,271
Evaluation results: No formal evaluation
Background
----------
The Roseland/Altgeld Adolescent Parent Project in Chicago serves
pregnant and parenting teenagers and their babies. RAPP's goal
is to decrease the negative social, health, and economic
79
APPENDIX I APPENDIX I
consequences of adolescent pregnancies by providing or assisting
clients to obtain comprehensive community based-services. To
accomplish this goal, the program has several objectives, which
include: (1) decreasing potential infant mortality and
morbidity, child abuse and neglect, and other negative
consequences associated with adolescent pregnancies; (2)
increasing healthy family functioning and well-baby care; (3)
providing access to the community's resources by networking and
participating in community organizations and coalitions; and (4)
decreasing the number of adolescent and repeat pregnancies among
elementary school girls.
RAPP began in 1980 as a component of the Catholic Charities'
Arts of Living Institute, a private, nonprofit social service
agency. The institute was established in 1973 to address the
many needs of pregnant adolescents. Its goal is to decrease
infant mortality, child abuse and neglect, and teen pregnancies
by sponsoring projects such as RAPP.
Catholic Charities formed RAPP to serve pregnant and parenting
females, age 11-20, in the Roseland and Altgeld Gardens
communities. Roseland is a neighborhood of older single-family
dwellings with high unemployment. Altgeld Gardens, a Chicago
Housing Authority project composed of row houses, is one of the
poorest areas in the city. The program targets teens who live in
these areas because of the high teenage pregnancy rates and poor
economic conditions. Over 25 percent of Roseland's teenage girls
became mothers, and one-third of the births in Altgeld are to
teen mothers.
Program Services and Activities
-------------------------------
The home visitors provide a variety of services either in the
home or in group meetings. These include (1) teaching well-baby
care, (2) administering the Denver Developmental Screening Test
to identify developmental problems infants may have, (3)
providing counseling, (4) observing parent/child relationships,
and (5) making referrals to other agencies. Referrals are a
major component of RAPP because the program cannot provide all
the assistance the participants need.
The staff includes a project director, a supervisor, five home
visitors, and a secretary. The director has a master's degree
and the supervisor a bachelor's degree in social work. Three of
the five home visitors have bachelor's degrees in social work;
however, a degree is not required. Most of the home visitors
come from the communities being served.
Home visitors' preservice training consists of a 1-week
orientation about the program's goals, objectives, and
80
APPENDIX I APPENDIX I
procedures. An experienced home visitor then accompanies them on
home visits for about 1 month. They receive regular in-service
training covering such topics as case management, working with
volunteers, and documenting client information.
The home visitors use a risk assessment to select the services
to provide each client. They followed general guidelines when
delivering services in the home. Program officials believe that
rigid guidelines would be inappropriate because unexpected
problems may arise, and the home visitors need flexibility to
address these problems.
The frequency of home visits varies depending on clients' needs.
The home visitors usually visit their clients once in the home
during pregnancy and weekly for up to 3 months after the baby is
born. In addition, the visitors encourage teens to attend weekly
support group meetings. The group follows a curriculum,
developed by the Minnesota Early Learning Design, to increase
self-esteem among the participants. Each meeting has a separate
theme and involves discussions in which the teens are encouraged
to share their experiences and feelings.
Program Results
---------------
RAPP does not have a formal evaluation system. Instead, program
officials monitor progress toward achieving objectives by
documenting and summarizing their contacts with and services
provided to clients. They send this information to Catholic
Charities' and the Ounce of Prevention Fund, which use it to
evaluate progress toward their overall goals.
Program Funding, Costs, and Benefits
------------------------------------
From 1986 to 1989, RAPP received funding from the state of
Illinois, Catholic Charities, and The Ounce of Prevention Fund, a
public/private partnership that funds and provides training for
programs that work with adolescent mothers to foster child
development. During 1986-88, total funding increased from
$194,600 to $327,300. The state's funding remained stable at
$55,000 each year. The Ounce of Preventions Fund's funding also
remained fairly constant at just over $100,000 each year.
Catholic Charities funded the remaining costs, which increased
from $39,000 to $168,200. Officials had not done a cost/benefit
analysis and did not have any figures on cost savings or future
cost avoidance.
Program Outlook
---------------
The program serves 160 to 175 clients per year. The director
would like to expand the program to serve more of the target
81
APPENDIX I APPENDIX I
population and to hire aides to take care of the babies during
group meetings.
82
APPENDIX I APPENDIX I
SOUTHERN SEVEN HEALTH DEPARTMENT PROGRAM: PARENTS TOO SOON AND
---------------------------------------------------------------
THE OUNCE OF PREVENTION COMPONENTS
----------------------------------
Table I.4: Program Profile: Southern Seven Health Department
Program (Parents Too Soon and The Ounce of Prevention Components)
Geographical areas served: Seven rural counties in
southern Illinois
Goals/objectives: Reduce negative effects
associated with teen
pregnancy, such as low
birthweight of infants
and the incidence of teen
pregnancies
Administrative agency: Southern Seven Health
Department
Service delivery method: Home visiting, workshops
Target population: Pregnant and parenting
teens, ages 10-20
Number and timing of intervention: Parents Too Soon
component--monthly
prenatal visits, and at 6
weeks and 6 months after
birth; Ounce of
Prevention component--
monthly postnatal visits
until baby is 12 months
old, and at 15 and 18
months of age
Home visitor qualifications: Bachelor's degree
Supervisory characteristics: Experienced home visitor
Number of home visitors: PTS--four; Ounce--three
Clients served: 65 percent of pregnant
teens in target area
Fiscal year 1988 funding: PTS--$224,695; Ounce--
$90,640
Evaluation results: Fewer low birthweight
infants born to program
83
APPENDIX I APPENDIX I
participants than
nonparticipants
Background
----------
The Southern Seven Health Department Program, which provides
services in seven southern Illinois counties, focuses on (1)
reducing the negative effects associated with teenage pregnancy,
(2) securing needed services for clients, and (3) reducing the
incidence of teenage pregnancy.
The program targets girls and young women, age 10 to 20, who are
at high risk for negative consequences of pregnancy and
parenting. They must reside in the seven counties, which
encompass a rural area of about 2,000 square miles.
The program is operated by the Southern Seven Health
Department's Social Services Division. The division director,
who reports to the Health Department administrator, administers
the program and supervises the home visitors.
The program, which began in early 1984, has two components with
separate staff. The Parents Too Soon (PTS) component is a state
program that attempts to deter teenage pregnancy and lessen the
negative consequences of adolescent pregnancy and childbearing.
It focuses primarily on pregnant teens during their prenatal
stage. Another component is supported by The Ounce of Prevention
Fund, a public-private entity concerned with healthy child
development. The staff of this component provide services to
teens after their child's birth. These components are offered
jointly to maximize the positive pregnancy and parenting outcomes
for teens enrolled in the program.
Program Services and Activities
-------------------------------
To accomplish the program's objectives, the home visitors
provide a variety of services. These include (1) teaching
prenatal and well-baby care, (2) ensuring that the client has a
medical provider and transportation to get there, (3) providing
information on family planning, (4) counseling clients about
infant development and behavior and budgeting and housekeeping,
and (5) referring clients to other agencies. The referrals are
an important program component because referral agencies can help
the teens with their medical, social, and educational needs. In
addition to home visits, the staff provide sex education and
prenatal workshops.
A multidisciplinary professional staff provides the program
services. The staff includes four social workers, two nurses,
and one nutritionist who make home visits, and one lay person
84
APPENDIX I APPENDIX I
whose primary responsibility is to help teens to remain in
school.
New home visitors receive 1 to 2 weeks of orientation about the
program. The PTS staff are not required to attend in-service
training; however, they may attend optional workshops on such
topics as preterm labor, nutrition, and stress management. The
Ounce of Prevention staff attend an annual conference and four
workshops each year on such topics as nutrition and parenting
skills.
When a client enrolls in the program, the home visitor does a
risk assessment to determine the client's needs and develops a
service delivery strategy to ensure that those needs are met.
When the client is near delivery, she is transferred to the Ounce
program and another assessment is done. To allow for
flexibility, the home visitors did not follow a structured
protocol during the home visits. However, as of January 1990,
the Ounce required its home visitors to follow a structured
curriculum that allowed flexibility.
The frequency of home visits varies by program component and the
client's needs. However, a general rule is that the PTS staff
see their clients once a month throughout pregnancy and again
when the baby is 6 weeks and 6 months of age. The Ounce home
visitors see their clients about once a month from the time the
baby is born until the baby is 12 months old and again at 15 and
18 months.
Program Results
---------------
The Southern Seven program does not have a formal evaluation
component. However, program statistics for 1984-87 show that in
3 of the 4 years, program participants had fewer low birthweight
infants than nonparticipants. In 1987, 2 percent of the
participants had low birthweight infants, compared to 12.5
percent of the nonparticipants.
Program Funding, Costs, and Benefits
------------------------------------
The program is funded by the state of Illinois and The Ounce of
Prevention Fund. Total funding in fiscal year 1988 was $315,300,
with 71 percent coming from the state and 29 percent from the
Ounce. Officials had not done a cost-benefit analysis and,
therefore, did not have any figures on cost savings or future
cost avoidance.
Program Outlook
---------------
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APPENDIX I APPENDIX I
The project director believes that the quality of the program's
services will suffer if it is not able to retain qualified staff
to deliver program services. In order to do so, the program
needs to offer the home visitors higher salaries. Thus far,
neither the state nor The Ounce of Prevention Fund has indicated
that it will increase program funding.
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APPENDIX I APPENDIX I
MATERNAL AND CHILD HEALTH ADVOCATE PROGRAM
------------------------------------------
Table I.5: Program Profile: Maternal and Child Health Advocate
Program
Geographical areas served: Detroit
Goals/objectives: Promote early use of
prenatal and child health
care to improve pregnancy
outcomes and infant
health
Administrative agency: Wayne State University
Medical School
Service delivery method: Home visiting
Target population: Women enrolled in
specific prenatal health
clinics or who had a
high-risk newborn
Number and timing of intervention: Up to 21 visits scheduled
throughout pregnancy and
until the baby reaches 1
year of age
Home visitor qualifications: High school diploma;
receiving public
assistance when hired
Supervisory characteristics: Master's degree in social
work or registered nurse
Number of home visitors: 21 originally hired; 9 as
program phased out
Clients served: First year--705; second
year--848
Fiscal year 1989 funding: $553,000
Evaluation results: Available in 1990
Background
----------
The Maternal and Child Health Advocate Program, in Detroit, was a
home-visiting project with the goal of promoting early and
87
APPENDIX I APPENDIX I
appropriate use of prenatal and child health care to improve
pregnancy outcomes and infant health. The project targeted
pregnant women enrolled in specific prenatal clinics and women
with high-risk newborns in the Children's Hospital of Michigan
neonatal intensive care unit.
The program, begun as a research project in June 1986 and ended
in October 1989, was administered by Wayne State University
Medical School's Department of Community Medicine. The
department's chairperson, a Department of Pediatrics professor,
and a Department of Obstetrics and Gynecology professor
codirected the project. The staff included a project
coordinator, who managed the program, and three teams, each of
which included a supervisor and four home visitors, called
advocates. In June 1988, the university's newly created
Institute of Maternal and Child Health began administering the
program using the same administrative structure.
Program Services and Activities
-------------------------------
The advocates provided case management, referral, and counseling
services in the home. Specifically, advocates (1) administered
assessment questionnaires, (2) counseled mothers regarding
pregnancy and related issues, (3) identified various resources
for health needs, and (4) provided referrals for other needs,
such as transportation, food, and clothing. The advocates also
provided emotional support. The advocates spent much of their
time making referrals because many of their clients had no
knowledge of available services and how to access them.
The advocates followed two types of structured protocols while
conducting home visits. The first was a needs assessment
administered at five points between the initial prenatal contact
and the baby's first birthday. The assessment covered the
clients' health, living conditions, and social problems and was
used to tailor services to the clients' needs. The second was
case management guidelines, which described a suggested minimum
number of visits and the appropriate services to be given at
various stages. For example, during the third trimester of
pregnancy, the visit's focus was on preparing for labor and
delivery and on using contraceptives after childbirth. The
guidelines recommended that each client receive up to 21 visits
scheduled throughout pregnancy and until the baby was 1 year old.
The number of visits would depend on when the client entered the
program. The advocates could deviate from the protocol to
address any current crises facing their clients.
Program staff were hired between June 1986 and March 1987, at
which time home visits began. The home visitors had to (1) be
receiving public assistance, (2) have a high school diploma, (3)
88
APPENDIX I APPENDIX I
work well with others, (4) be Detroit residents, and (5) be
familiar with the city's social service system. The program also
tried to hire persons who were caring and culturally sensitive
and had good interpersonal skills. Two of their supervisors had
master's degrees in social work, and one was a registered nurse.
The home visitors received 6 weeks of preservice training.
Topics included human growth and development, human enhancement
skills, community resources and how to use them, and the role of
a paraprofessional. They attended monthly in-service training
covering such topics as parenting resources and skills and AIDS
and pregnancy.
Program Results
---------------
Program effectiveness was determined by comparing clients
receiving full program services to two other groups. The three
groups were (1) a home visitor group who received regular home
visits until their infants' first birthday, (2) a research
control group who received occasional visits, and (3) a
comparison group who received no visits. Evaluation results were
to be available in 1990.
Program Funding, Costs, and Benefits
------------------------------------
The program received funding from the Michigan Department of
Health, the Ford Foundation, and VISTA during its 40-month
existence. During this period, the state provided $877,000 used
primarily for services, and the Ford Foundation provided $509,000
used primarily for evaluation during the first 2 years. VISTA
provided funds that were used to pay subsistence allowances
instead of salaries to the home visitors. Increased state
funding during the third year was used to pay the home visitors a
salary. Program officials did not have any data on cost savings
or future cost avoidance.
Program Outlook
---------------
The Maternal and Child Health Program ended in October 1989. At
that time, the Institute of Maternal and Child Health began a new
prenatal/postnatal home-visiting project. The new program was
designed to reach pregnant women who are not getting prenatal
medical care by emphasizing community participation. To do this,
program officials planned to increase the presence of supportive
community personal networks for women with children and establish
a local advisory board consisting of health and social service
providers, community leaders, and residents. The new project
focuses on pregnant women and parents of young children from four
communities in Detroit's Eastside. The project is funded by HHS
and the Michigan Department of Public Health.
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APPENDIX I APPENDIX I
CHANGING THE CONFIGURATION OF EARLY PRENATAL CARE
-------------------------------------------------
Table I.6: Program Profile: Changing the Configuration of Early
Prenatal Care (EPIC)
Geographical area served: Providence
Goals/objectives: Improve pregnancy
outcomes, health care and
coping skills; reduce low
birthweight
Administrative agency: Rhode Island Department
of Health
Service delivery method: Home visiting
Target population: Inner-city, low-income,
high-risk women
Number and timing of intervention: 8-10 weekly visits during
20-30-week gestation
period
Home visitor qualifications: Bachelor's degree in
nursing; home-visiting
experience
Supervisory characteristics: Master's degree in
nursing; home-visiting
experience
Number of home visitors: 2
Clients served: 280
Total program funding: $459,545
Evaluation results: Not completed
Background
----------
The Changing the Configuration of Early Prenatal Care project in
Providence was a preventive public health program. The project
addressed risk factors amenable to change among women at high
risk for having low birthweight infants. EPIC's goal was to
improve the pregnancy outcomes for high-risk, inner-city women
through mid-pregnancy prenatal care home intervention. To
accomplish this goal, the project sought to (1) increase the
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APPENDIX I APPENDIX I
average number of prenatal doctor visits from 8 to 10; (2)
improve the nutritional status, lifestyle behavior, and health
care utilization of clients served; and (3) reduce the incidence
rate of low birthweight by 30 percent among the target
population.
Services were provided to inner-city, low-income, high-risk
pregnant women who registered for prenatal care during March
1987 and June 1989 at two inner-city Providence Maternal and
Child Health clinics. They also had to (1) be less than 20 weeks
pregnant, (2) live in a census tract with a higher than average
percentage of low birthweight babies, and (3) agree to
participate in the project.
EPIC, begun as a research and development project in October
1986, was administered by the Rhode Island Department of
Health's Division of Family Health. The division's special
projects and evaluation section chief was the EPIC project
director with responsibility for administering and evaluating the
program. The Department of Health contracted with the Visiting
Nurses Association, Inc. (VNA), for two nurses and a supervisor
to provide EPIC services.
Program Services and Activities
-------------------------------
EPIC provided services in five broad areas: (1) medical prenatal
services, (2) other medical and social community services, (3)
substance abuse, (4) nutrition, and (5) coping with stress.
Services were provided through 8 to 10 weekly home visits between
the 20th and 30th weeks of pregnancy and referrals to other
providers. Based on observations, questions, and the woman's
medical background, the nurses determined her knowledge,
resources, and support as they related to each of the five
service areas. The nurses then placed each woman into one of
three modules for each service area, depending on the intensity
of need. They also used interpreters to assist in providing
services to their non-English-speaking clients, including
Hispanic and Southeast Asian women.
The nurses followed a protocol during the home visits; however,
they could deviate from it if the clients had other concerns
that needed to be addressed. During the home visits, the nurses
provided information that specifically related to the women's
needs. Examples included the effects of substance abuse on fetal
development, how to apply for food stamps, and the importance of
eating well-balanced meals. The nurses also referred the program
participants to other agencies that could provide services that
the EPIC program did not provide, such as drug counseling and
Medicaid. No services were provided after the child was born.
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APPENDIX I APPENDIX I
The EPIC nurses had bachelor's degrees in nursing, had several
years of home-visiting experience, and were selected because they
were compassionate, honest, and able to easily establish a
rapport with others. The supervisor had a master's degree in
nursing and extensive home-visiting experience. Since the nurses
had prior home visiting experience and were knowledgeable about
the local service provider network, the program did not include
formal preservice or in-service training.
EPIC provided services from March 1987 through June 1989. Of the
1,160 women to whom the program was offered, 559 agreed to
participate. Half of these women received home visits, while the
other half served as a control group for evaluation purposes.
Program Results
---------------
Program officials used a randomized controlled trial research
design to evaluate the program. At the time of our visit in June
1989, formal evaluation was just beginning. Consequently,
conclusions had not been drawn regarding whether the program had
achieved its three major goals. However, the preliminary
evaluation results indicated that the project had positively
affected the pregnancy or lives of the women who received home
visits. For example, preliminary posttest evaluation results
showed a 55-percent increase in the number of women enrolled in
WIC for program participants in comparison to a 38-percent
increase for the control group. The program director planned to
complete the evaluation by spring 1990.
Program Funding, Costs, and Benefits
------------------------------------
EPIC was funded entirely by a 3-year $459,545 federal SPRANS
grant. Based on VNA estimates, the average intervention cost
$23.30 per hour. This included salaries, benefits, and
transportation expenses for the nurses, escorts, and
interpreters, but not overhead or supervisory expenses incurred
by VNA or evaluation expenses incurred by the state. The total
VNA cost per visit including overhead depended on the number of
visits made each day. While the program operated, about three
visits were made each day; VNA estimated that the average cost
was $87 per visit.
Program officials did not have any figures on cost savings or
future cost avoidance. This information was to be developed as
part of the program evaluation.
Program Outlook
---------------
The program ceased to function in June 1989. The project
director speculated that if evaluation results were positive, the
92
APPENDIX I APPENDIX I
program might be funded with state funds or federal MCH block
grant funds. In the interim, no attempts were being made to
continue EPIC services. Evaluation results were also to be used
to refine the program's objectives and services, if necessary.
If the program were continued, it would be administered by the
Department of Health's Preventive Services Section, which would
integrate EPIC services with other state-funded services. The
department would continue to contract with VNA for delivery of
program services.
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APPENDIX I APPENDIX I
GREAT BRITAIN'S HEALTH VISITOR PROGRAM
--------------------------------------
Table I.7: Program Profile: Great Britain's Health Visitor
Program
Geographical areas served: Great Britain (England,
Scotland, Wales, and
Northern Ireland)
Goals/objectives: Promote sound mental,
physical, and social
health of children by
educating families
Administrative agency: District health
authorities
Service delivery method: Home visiting
Target population: Children from birth
through age 5
Number and timing of intervention: One prenatal visit plus
five visits from birth
through age 5
Home visitor qualifications: Registered nurses with
special graduate-level
education
Supervisory characteristics: Previous health-visiting
experience
Number of home visitors: One health visitor per
3,000 people
Clients served: All children in Great
Britain
Fiscal Year 1989 funding: Not available
Evaluation results: No evaluation done
Background
----------
Home health visiting in Great Britain began in 1852, when
members of the Manchester and Saltford Ladies Sanitary Reform
organization began to visit poor families in their homes to
improve their health knowledge and practices. By 1905, 50 areas
employed health visitors. The 1907 Notification of Births Act
94
APPENDIX I APPENDIX I
established a procedure to notify responsible authorities,
including health visitors, when a baby was born; this became
mandatory in 1915.
The goal of health visiting in Great Britain is to promote
health and to prevent mental, physical, and social ill health in
the community. The primary focus is on maternal and child health
care, and the expected outcome is reduced infant mortality and
morbidity rates.
All British residents are eligible for health-visiting services;
however, the health visitors target children from birth through
age 5. The program further targets children who are at risk due
to inadequate housing and improper nutrition.
In Great Britain, the Health Ministers in England, Wales,
Scotland, and Northern Ireland have responsibility for health
services. In England, there are 14 regional health authorities
and 191 district health authorities. The district authorities
employ health visitors who, together with general practitioners
and midwives, make up a primary health care team. The general
practitioner and the midwife provide prenatal care at community
health clinics, while the health visitor provides postnatal
services in the home.
Program Services and Activities
-------------------------------
During a health visit, the focus is on health promotion and
education, immunization, and screening and surveillance of
infants. Education is the primary method health visitors use to
help families make sound, informed decisions. Specifically, the
health visitors emphasize such things as breast-feeding, infant
immunizations, accident prevention, and appropriate health care.
The health visitors also monitor the child's development so that
potential problems, such as poor hearing, can be identified and
addressed as soon as possible. They also make necessary
referrals for medical care or social services.
The health visitors follow general guidelines when delivering
services. Typically, six home visits are made per pregnancy: one
prenatal visit when the health visitor describes her role and
available services to the family and five postnatal visits before
the child enters school. During each visit, the health visitors
have flexibility to address any unanticipated problems. Each
child also receives hearing and mobility screening tests in a
clinic at about 7 to 9 months of age and another clinic screening
of vision, hearing, social skills, and physical and emotional
development at 2-1/2 to 3 years of age.
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APPENDIX I APPENDIX I
In most cases, the health visitor independently provides the
advice, guidance, and education that families need. However, she
has a close working relationship with other community support
agencies that handle psychological, social, and legal problems
that she is not qualified to handle.
All health visitors are registered general nurses and have
completed a postgraduate health visitors course that requires 51
weeks of academic and practical training. The curriculum
includes such topics as human growth and development and social
policy and administration. After completing the course, health
visitors are given a small caseload under supervision. After
certification, the health visitor receives in-service training
from her employing health authority. The training generally
consists of refresher courses and seminars.
Senior nursing officers, who are experienced health visitors,
supervise the health visitors. They usually supervise about 25
visitors, but this varies by district. However, the health
visitors receive little direct oversight from supervisors.
Program Results
---------------
Program officials have not formally evaluated the effectiveness
of health visiting. However, public health officials believe the
effects of health visiting are positive.
Program Funding, Costs, and Benefits
------------------------------------
In Great Britain, total health service expenditures increased by
229 percent from $14 billion in 1978 to $46 billion in 1989, not
considering inflation or currency fluctuations.#44 Health
officials could not tell us the amount of health service
expenditures spent on health visiting and did not know how much
health visiting cost. They also had not done a cost-benefit
analysis and did not have any figures on cost savings or future
cost avoidance.
Program Outlook
---------------
Because of rising costs and increasing demands for health
services, the British Government is beginning to demand more
accountability. The prospect of productivity-oriented reforms in
the National Health Service will cause all health professions to
begin determining the costs and outcomes of their services. To
this end, program officials are beginning to develop management
44The annual average exchange rate for the pound sterling for
1988 was $1.780805=1 pound.
96
APPENDIX I APPENDIX I
information systems to monitor the amount and type of health
visitor services delivered and to measure their success in
meeting the program's objectives.
97
APPENDIX I APPENDIX I
DENMARK'S INFANT HEALTH VISITOR PROGRAM
---------------------------------------
Table I.8: Program Profile: Denmark's Infant Health Visitor
Program
Geographical area served: 273 of 277 municipalities
Goals/objectives: Reduce infant mortality
by promoting the health
and well-being of
children
Service delivery method: Home-visiting and
parenting classes
Target population: Children through age 6
Number and timing of intervention: Tailored to clients'
needs
Home visitor qualifications: Professional nurse who
completed an advanced
program in public health
nursing
Supervisory characteristics: Public health nurse
Number of home visitors: On average, 1 per 120
children
Clients served: 90 percent of all infants
as of 1976
Fiscal year 1989 funding: Not available
Evaluation results: No evaluation done
Background
----------
Home health visiting in Denmark began in 1932 as a pilot program
in response to the country's high infant mortality rate. Four
nurses went to four geographical areas in Denmark and visited
each newborn at least 12 times during the first year of life. In
1937, after 6 years of what the government characterized as
positive findings, the Danish Parliament passed a law allowing
municipalities in Denmark to employ public health nurses as
health visitors. The law did not make the service compulsory,
but the government offered to subsidize 50 percent of the health-
visiting costs for municipalities that chose to participate.
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APPENDIX I APPENDIX I
Additional legislation was passed in 1946, 1963, and 1974 to
strengthen the original law.
The purpose of home health visiting in Denmark, hereafter
referred to as health visiting, is to promote the health and
well-being of children. The health-visiting program focuses on
the preventive mental, social, and environmental factors that
combine to influence the behavior of mothers and their children.
The program targets children from birth to age 6.
Health visiting in Denmark is a component of a preventive health
care system to which all citizens have free access. As of 1985,
273 of the 277 municipalities in Denmark employed a health
visitor. Individuals and families can refuse health-visiting
services, but less than 2 percent do so.
Health visitors are employed at the municipal level by the
Director of Social and Health Administration and belong to a
primary health team that includes general practitioners and
midwives. The director oversees the health visitor services.
For the most part, the health visitors function independently,
planning and scheduling their own work. Most municipalities are
small and do not employ a health visitor supervisor.
Program Services and Activities
-------------------------------
The health visitors provide many services designed to influence
parental behavior and decrease children's health problems. They
perform routine health checkups for infants and answer new
mothers' questions about feeding, diapering, illnesses, and the
baby's development. They also test the child for sight, hearing,
and motor development. In addition, nurses help mothers with
other needs, including obtaining transportation to a clinic or
assisting with domestic problems and stress management. To
supplement the health visits, some municipalities offer parenting
classes and programs for the mother, such as parent group classes
and open houses. During the classes, the parents and health
visitors discuss such topics as nutrition, diet, and infant
stimulation. Open houses are held once a week at the health
visitor's office, where mothers and their babies come to interact
with one another.
A basic principle of Denmark's overall health policy is the
coordination and cooperation of various health and social
services. The health visitor is responsible for establishing
continuity in preventive, curative, and outreach services for the
families served. The health visitor fosters cooperation with a
host of other agencies, because while highly skilled, the health
visitor is not equipped to handle all the problems that might be
encountered, such as alcoholism and child abuse.
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APPENDIX I APPENDIX I
The health visitor has flexibility in conducting the home
visits. A standardized program delivery strategy is followed;
however, each visit is tailored to address conditions prevailing
at that time. The number and frequency of visits is based on the
health visitor's assessment of the physical, social, and
environmental conditions of the child and family. However, a
child and family who are not at risk will receive five visits
during the child's first year.
To become a health visitor, a person must (1) be a professional
nurse, (2) complete an advanced program in public health nursing,
and (3) pass an exam covering the principles and practices of
public health nursing and organization and administration. The
health visitors do not attend scheduled inservice training;
however, each year, they may attend a Danish Nurses Organization-
sponsored conference. Topics covered include the latest health
prevention strategies, psychology, and communications.
Program Results
---------------
Since the pilot program in the 1930s, health visiting has not
been evaluated to measure its effectiveness. Public health
officials in Denmark believe that health visiting is an important
part of preventive health care and that it promotes wellness by
developing healthier children, which leads to a lower infant
mortality rate.
Program Funding, Cost, and Benefits
-----------------------------------
In 1985, Denmark spent $4.9 billion,#45 or 5.5 percent of its
gross national product, on public health services, including
health visiting. Program officials do not collect data on the
cost of health visiting services. They have not done a cost-
benefit analysis and had no figures on cost savings or future
cost avoidance.
Program Outlook
---------------
Raising health standards through preventive health is of great
importance in Denmark. Because of this, health visiting will
continue to be a government priority. However, health visiting
may change in the near future. In 1987, the Danish Minister of
Health proposed consolidating all health care legislation. This
action, which may take effect in January 1991, may make health
visiting mandatory. The legislation may also allow the
45The annual average exchange rate for the Danish kroner for
1988 was $1.00=6.72809 kroner.
100
APPENDIX I APPENDIX I
municipalities to hire professionals other than nurses, such as
social workers, to provide health-visiting services.
101
APPENDIX II APPENDIX II
WHAT HAPPENS ON A HOME VISIT?
-----------------------------
GAO staff accompanied home visitors at every site we visited.
The following descriptions illustrate the variety of situations
encountered by home visitors.
AIKEN COUNTY, RURAL SOUTH CAROLINA
----------------------------------
Purpose of visit: To support and educate a teenager close to
delivery.
Provider: Paraprofessional, Resource Mothers Program.
The client was 13 years old, 8-1/2 months pregnant, a victim of
child abuse and, currently, a ward of the state. The visit took
place in her grandmother's trailer--where the client had often
returned when running away from her foster homes. The home
visitor had to knock several times and call the client's name
before the door would open. The trailer was cluttered and
cramped, and the young woman was dressed in a windbreaker with
what appeared to be only a slip beneath it. The client was not
feeling well and complained of an aching back. When the home
visitor asked if the baby was moving actively, the client
indicated that she had not felt much movement since her mother
had kicked her in the stomach during an argument. Concerned
about the health of the unborn baby, the home visitor urged the
client to see her doctor. Because the baby was almost due, the
home visitor and the girl discussed contingency plans in case the
client was alone during labor. The home visitor reminded the
girl that she could call 911 if she needed help. The home
visitor stressed the importance of good nutrition for the
remainder of the girl's pregnancy. The girl promised to call her
home visitor as soon as the baby was born.
AUSTIN, TEXAS
-------------
Purpose of visit: To work on fine motor, language, and cognitive
skills with developmentally delayed child.
Provider: Professional, CEDEN program.
A small apartment was home for the mother, her four children,
and, periodically, her husband. Program services were directed
to the youngest of this Hispanic family--a 26-month-old girl
with delayed speech development. The home visitor moved through
a number of speech, fine motor, and cognitive development
exercises, including sounds and pictures of animals, bead
stringing, and puzzles of different shapes and sizes. The
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APPENDIX II APPENDIX II
mother, 32 years old with a seventh grade education, was included
in these structured activities. The mother spoke to the child in
a mixture of Spanish and English. The home visitor encouraged
the mother to speak more often to the child. Though the child
had made progress, she was still quite shy and rarely spoke. She
would, however, frequently look at the family's visitors and
smile. The home visitor was trying to schedule a speech
assessment for the child at the University of Texas.
ANNA, A SMALL TOWN IN RURAL ILLINOIS
------------------------------------
Purpose of visit: To educate and support a teen mother.
Provider: Professional, Southern Seven Program
The teen mother seemed happy to see the home visitor. Though the
family--a 17-year-old-mother, her husband, and their 15-month-
old-child--had just moved into a public housing project the week
before, their apartment was neat and clean. The mother was home
alone with her daughter; her husband was at work. The home
visitor covered a number of topics relating both to the child's
development and the mother's goals. She checked if the child had
been immunized and had reached developmental milestones, such as
feeding and undressing herself. The mother and home visitor
discussed positive child discipline practices, such as rewarding
for good behavior and making the child sit in the corner instead
of physically punishing her. The home visitor gave information
on child development and enrolling the child in Head Start. They
discussed birth control methods. The mother told the home
visitor she was planning to return to school and planned to keep
her birth control appointment, since she did not want more
children. According to the home visitor, her short-term goals
were to have the mother pass her high school equivalency exam
and increase her parenting skills. The home visitor would like,
in the long term, to see this mother become more self-confident
and employed.
ALTGELD GARDENS, A HOUSING DEVELOPMENT IN URBAN CHICAGO
-------------------------------------------------------
Purpose of visit: To discuss the mother's needs, the child's
development, and the home situation since the last visit.
Provider: Paraprofessional, RAPP program.
This 19-year-old mother of a 19-month-old daughter had been a
client of the program for almost 2 years. The mother had not
had an easy life. She had been sexually assaulted by a number of
family members and forced to leave her family by her mother--who
had also been a teen mother--when she became pregnant. After her
child's birth, the client moved from her aunt's home to a
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APPENDIX II APPENDIX II
boyfriend's, then to a grandfather's in another state, to a
girlfriend's, and, finally, back to her mother's. According to
the client, her life had begun to improve, due in part to RAPP.
She had started a full-time job, found a baby sitter close to
home, and planned to enter college in the fall. Though her
current living situation still produced problems, finding
employment had helped. The home visitor informed the mother
about sources of financial support for college. In addition, the
home visitor gave the mother suggestions for developmental
activities for the child. The home visitor would see this client
again that week at the program's group meeting.
HOLBAEK, A SMALL TOWN IN DENMARK
--------------------------------
Purpose of visit: To check on the status of breast-feeding,
weigh the child, and respond to the mother's questions.
Provider: Professional nurse.
This was the home visitor's third visit to a young family with
their first baby. The mother was 25 years old and not married to
the father, a 26-year-old mason. Their baby was a few weeks old.
Their home was spacious and well furnished. The home visitor's
goal for this visit was to chart the child's growth and
development and answer any questions of the mother. After
weighing the baby and recording her progress, the home visitor
discussed immunization with the mother, suggesting that the baby
get her first vaccination soon. The baby had a skin rash, which
the home visitor diagnosed as merely dry skin. She advised the
mother on preventing such rashes in the future and encouraged
both parents to attend evening parents' group meetings. The
mother asked about her baby's crying patterns. The home visitor
reassured her that everything appeared to be normal. After the
visit ended, the home visitor told us that would be her last
visit for a while, since the family was considered a "no-problem"
household. Contact with this family would be maintained through
the parents' group.
MID GLAMORGAN HEALTH DISTRICT, RURAL WALES
------------------------------------------
Purpose of visit: To physically check children and assess living
conditions of higher risk families.
Provider: Professional nurse.
The two families visited were living in trailers in a gypsy
caravan park. These nomadic families travel throughout Great
Britain, parking on vacant or public lands. This caravan park
was very dirty and lacked running water. A water pump was
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APPENDIX II APPENDIX II
available down the road. Both families had troubled histories of
alcohol, violence, or child abuse.
One family's 6-year-old and 2-1/2-year-old were checked for
scabies (parasitic mites that burrow under the skin) as a follow-
up to a clinic visit. This family had recently lost a third
child in a hit-and-run accident. Although the mother did not
appear to be very receptive to advice, the home visitor felt she
was making progress because the mother had brought the children
into the clinic to get treatment.
The second family had seven children and an alcoholic, violent
father. The prior year, the father had set fire to their caravan
with one child still inside, who escaped unharmed. The home
visitor spent much of the visit discussing birth control with the
mother. According to the home visitor, the mother was
conscientious and receptive to advice. This was not the norm,
however. In the home visitor's opinion, many gypsy families
resist authority of any kind. These families needed to be
visited more frequently because of their many problems.
OXFORDSHIRE HEALTH DISTRICT, SUBURBAN LONDON
--------------------------------------------
Purpose of visit: To check on the health progress of a toddler.
Provider: Professional nurse.
The home visitor made a routine visit to an 18-month-old and the
child's mother, a 23-year-old Indian woman married to an older,
unemployed man with a heart condition. The child was
overweight, so the home visitor spent most of the visit
discussing proper child nutrition and its importance to normal
development. In the opinion of the home visitor, nutrition and
health issues are often culturally based. The mother seemed set
in her ways and might not be open to new influences. These
cultural differences presented a problem for home visitors, who
were trying to ensure that families followed the best modern
health practices.
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APPENDIX III APPENDIX III
COMMENTS FROM THE DEPARTMENT OF EDUCATION
-----------------------------------------
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instructions on the first page.)
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APPENDIX IV APPENDIX IV
COMMENTS FROM THE DEPARTMENT
----------------------------
OF HEALTH AND HUMAN SERVICES
----------------------------
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instructions on the first page.)
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APPENDIX V APPENDIX V
MAJOR CONTRIBUTORS TO THIS REPORT
---------------------------------
HUMAN RESOURCES DIVISION, WASHINGTON, D.C.
------------------------------------------
Kathryn G. Allen, Project Director, (202) 275-8894
David D. Bellis, Project Manager
Sheila Avruch, Evaluator
Hannah F. Fein, Writing Specialist
ATLANTA REGIONAL OFFICE
-----------------------
Shellee S. Soliday, Deputy Project Manager
Cheri Y. White, Evaluator
CHICAGO REGIONAL OFFICE
-----------------------
Adrienne F. Friedman, Site Senior
Judith A. Michaels, Evaluator
EUROPEAN OFFICE
---------------
Charles F. Smith, Site Senior
Ann Calvaresi-Barr, Evaluator
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