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Rcport~t,o that Chairman, Subcommittee on Labor, Health and Human Services, Mncation, and Related Agencies, Committee on Appropriations, I J.S.Senate HOME VISITING A Promising Early Intervention Strategy for At-Risk Families 141782 , IW3TIU~---Not to be released outside the General Acco~ OBlce unless spedilcal$ approved w the Office of Congre B?B@thk @TK~EASED . -. _. -._-- ... - -.,-. .-_.-._ -. - ~;AO/JIIlJ)-!~O-8:J Comptroller General of the United States 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 Executive Summ~ Families that are poor, uneducated, or headed by teenage parents often Purpose 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 vis- iting. 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 opportuni- ties to expand the use of home visiting? The Senate Appropriations Sub- committee on Labor, Health and Human Services, Education, and Related Agencies asked GAO to answer these questions. Background 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-pre- natal visits, health education, parenting education, home-based pre- school, and referrals to other agencies and services. While home visiting can also be used to deliver services to the chroni- cally ill and the elderly, this report focuses on delivering early interven- tion 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. Home visiting is a promising strategy for delivering or improving access Results in Brief 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 depen- dency. While few cost studies of home visiting have been done, they have shown that 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 interven- tion services, has not been well researched. Page2 4,’” . Executive Summary Not all programs that use home visiting have met their objectives. Suc- cess depends on a program’s design and operation. Well-designed pro- grams 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 coordi- nated 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 prac- tical knowledge developed at the federal, state, and local levels. GAO’s Analysis Home Visiting Can Be an Evaluations of early intervention programs using home visiting demon- Effective Service Delivery strate that these programs can improve both the short- and long-term health and well-being of families and children. Compared to families Strategy 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 develop- ment. Evaluations of home visiting that examined costs have demon- strated 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. (See pp. 29-38,) 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. (See pp. 31-34.) Characteristics That Although many early intervention programs using home visiting have Strengthen PKogram succeeded, others have failed to meet their stated objectives. Evaluators have attributed such failures to fundamental problems with program Design and design and operation. (See pp. 39-42.) GAO identified critical design com- Implementation ponents for developing and managing programs using home visiting that Page 3 Executive Summary 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 strat- egies for secure funding over time. (See pp. 42-43 and ch. 6.) Federal Commitment Can HHS and Education support home visiting through both one-time demon- stration projects and ongoing funding sources, such as Medicaid (a Be Better Coordinated and federal-state medical assistance program for needy people). But federal Focused managers were not always aware of results in other agencies, materials developed through federally funded efforts, or state and local home- visiting efforts. (See pp. 21-23.) The Federal Interagency Coordinating Council is a multiagency body that attempts to mobilize and focus federal efforts on behalf of handi- capped 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 collabo- ration on joint agency projects. (See pp. 24-26.) Federal demonstration projects could be better focused to improve pro- gram design and fill information voids. Federal managers should empha- size 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. (See pp. 21-23 and 66-68.) 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 Con- gressional Budget Office estimated that the additional federal fiscal year 1990-94 Medicaid costs for this initiative would range from $96 million, if home visiting were made an optional Medicaid service, to $626 million, if mandatory. (See pp. 26-28.) Page 4 GAO/HRD-30-33Home Visiting I’ . : Jheeutlve Summary In view of the demonstrated benefits and cost savings associated with Matter for home visiting as a strategy for providing early intervention services to Congressional improve maternal and child health, the Congress should consider Con&deration amending title XIX of the Social Security Act to 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. (See p. 63.) GAO recommends that the Secretaries of HI-E and Education require fed- Recommendations erally supported programs that use home visiting to incorporate certain critical program design components for developing and managing home- visiting services. (See p. 63.) 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 l 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-vis- iting services, and . charge the Federal Interagency Coordinating Council with the federal leadership role in coordinating and assisting home-visiting initiatives. (See pp. 63-64.) HHS and the Department of Education generally concurred with GAO'S Agency Comments conclusions and recommendations. (See pp. 64-66 and apps. III and IV.) Both agreed with the need for more research and evaluation of the costs and benefits of home visiting. Without such data, they expressed reluc- tance to give priority to home visiting over other early intervention ser- vice 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, HH!3stated 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 ser- vice would send a clear message to states about the efficacy of home visiting, especially for high-risk pregnant women and infants. Page5 1 Contents Executive Summary 2 Chapter 1 10 Introduction What Is Home Visiting? Some Families Face Service Barriers 10 11 Home Visiting as an Early Intervention Strategy 13 Objectives, Scope, and Methodology 16 Chapter 2 17 Home Visiting Is an Home Visiting Widespread in Europe 17 US. Home Visiting Targeted to Low-Income and Special 19 Established Service Needs Families Delivery Strategy Funding for US, Home Visiting From Multiple Agencies 21 With Multiple New Impetus for Home Visiting From Recent Legislation 24 Objectives Chapter 3 Home-Visiting Program Evaluations Show Benefits of Home Visiting Research Shows Home Visiting Compared to Other Evaluations Strategies Is Promising, but More Study Is Needed Demonstrate Benefits, Limited Research Shows Home Visiting Can Produce Cost 36 but SomeQuestions Savings Remain Chapter 4 39 Poor Program Design Poor Program Outcomes Linked to Design Weaknesses Critical Components for Program Design 39 42 Can Limit Benefits of Home Visiting Chapter 5 44 A Framework for Clear Objectives as a Cornerstone 46 Structured Program Delivered by Skilled Home Visitors 48 Designing Programs Strong Community Ties in a Supportive Agency 62 That Use Home Ongoing Funding for Program Permanency 66 Visiting + Page 6 GAO/lU?DM Home Visiting I Contenta Chapter 6 59 Conclusions, Conclusions Matter for Congressional Consideration 59 63 Recommendations, Recommendations 63 and Agency Comments Agency Comments 64 Appendixes Appendix I: Description of the Eight Home-Visiting 68 Programs GAO Visited Appendix II: What Happens on a Home Visit? 94 Appendix III: Comments From the Department of 98 Education Appendix IV: Comments From the Department of Health 101 and Human Services Appendix V: Major Contributors to This Report 107 Tables Table 1.1: Early Intervention Saves Money 14 Table 2.1: Home Visiting in Nine Western European 18 Countries ; Table 2.2: Federal Programs Used to Fund Home Visitor 22 Projects Table 2.3: Signatories to the FICC Memorandum of 25 Understanding Table 6.1: Characteristics of United States and European 45 Programs GAO Visited Table I. 1: Program Profile: Center for Development, 68 Education, and Nutrition (CEDEN) Table 1.2: Program Profile: Resource Mothers for 72 Pregnant Teens Table 1.3: Program Profile: Roseland/Altgeld Adolescent 76 Parent Project (RAPP) Table 1.4: Program Profile: Southern Seven Health 79 Department Program (Parents Too Soon and the Ounce of Prevention Components) Table 1.6: Program Profile: Maternal and Child Health 82 Advocate Program Table 1.6: Program Profile: Changing the Configuration of 85 Early Prenatal Care (EPIC) Table 1.7: Program Profile: Great Britain’s Health Visitor 88 Program Table 1.8: Program Profile: Denmark’s Infant Health 91 Visitor Program Page 7 GAO/HRD-90-83Home Visiting I Conants Figures Figure 1.1: Examples of Programs Using Home Visiting to 11 Serve At-Risk Families Figure 3.1: Students Receiving Preschool and Home- 32 Visiting Services Were More Successful in Later Years Figure 3.2: Type and Amount of Services Affect Later 34 Reading Ability Figure 6.1: Framework for Designing Home Visitor 46 Services 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 FtAPP Roseland/Altgeld Adolescent Parents Program SPRANS Special Projects of Regional and National Significance VISTA Volunteers in Service to America VNA Visiting Nurses Association, Incorporated WIG Special Supplemental Food Program for Women, Infants, and Children Page8 GAO/I3RB30-33 Home Visiting Page 9 GAO/HRD-90-33Home Visiting 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 edu- cational 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 pro- viding more expensive crisis, curative, and remedial services. But what can home visiting do for those families facing many intercon- nected 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 Appro- priations Subcommittee on Labor, Health and Human Services, Educa- tion, 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. Home visiting is a strategy that delivers health, social support, or educa- What Is Home tional services directly to individuals in their homes. Programs use home Visiting? 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 refer- rals 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. Page 10 GAO/~9083 Home Visiting t chaptm 1 introduction -, FIQWO1.1: Example8 of Program8 Ualng Home Visiting to Serve At-Rlrk Familleo Qoalr: 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 fam- ilies for more intensive services, providing more frequent home visits over 1 or more years. Home visits may be part of other program ser- vices, which can include center-based parenting classes and job training classes, and developmental day care or preschool for children. At-risk families, especially those who are poor, uneducated, or headed SomeFamilies Face by teenage parents, often face barriers to getting the health, education, Service Barriers 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-Q.6 million-have no health insurance at all. We reported in 1987’ that ‘Prenatal Care: Medicaid Recipients and Uninsured Women Obtain Insufficient Care (GAO/ Page 11 GAO/HRD-90-83Home Visiting I * chapter 1 Introduction Medicaid2 recipients and uninsured women received later and less suffi- cient prenatal care than privately insured women from the same com- munities. 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 sys- tems 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 num- bers 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 (WIG) 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 ser- vices, does not exist for at-risk families. Personal beliefs, knowledge, and attitudes can present additional bar- riers to getting care. Some researchers have found that some low-income ‘Medicaid is a federally aided, state-administered medical assistance program for needy people, authorized under title XIX of the Social Security Act. %stitute of Medicine, Prenatal Care: Reaching Mothers, Reaching Infants, ed. by Sarah S. Brown (Washington, DC.: National Academy Press, 1988>,pp. 63-69. Page 12 GAO/HRD-90-83Home Visiting i chapter 1 Introduction families do not understand or value the need for preventive services. They may distrust health care providers or social workers. These per- sonal 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 Mor- tality, 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 is often used as one means to provide early intervention Home Visiting as an services. Early intervention seeks to improve families’ lives and prevent Early Intervention problems before they become irreversible or extremely costly. For example, . prenatal care seeks to promote the health and well-being of the expec- tant mother and developing fetus, thereby reducing poor birth out- comes, such as low birthweight; l parenting skills instruction for adolescent mothers with infant children seeks to promote nurturing skills, thereby reducing abusive and neg- lectful 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 Page 13 GAO/HUD9043 Home Visiting chapter 1 Introduction birthweight babies in neonatal intensive care is $1.5 billion annuallye 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.” The imme- diate, 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,Oand 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 $600,000 and $1 million. Researchers have reported the potential of this and other early inter- vention 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.l : Early Intervention Saves Money Every $1 spent on: Saves.... The federal Childhood Immunization Program $10 in later medical costs.(l) 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) Sources: 1. University of North Carolina Child Health Outcomes Project, Monitoring the Health of America’s Chil- dren, - 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. 4”Special Report: Perlnatal Issues 1989,” American Hospital Association, Chicago (1989), p. 2. ““Teenage Pregnancy and Too-Early Childbearing: Public Costs, Personal Consequences,” Center for Population Options, Washington, DC. (1989), p. 3. “Deborah Daro, Confronting Child Abuse: Research for Effective Program Design, The Free Press, New York (1988) pp. 165-67. 7Children in Need: Investment Strategies for the Educationally Disadvantaged, The Committee for Economic Development, New York (1987), p. 3. Page 14 GAO/HRD-90-83Home Visiting Chapter 1 Introduction Our objectives in reporting on home visiting were to determine Objectives, Scope,and Methodology l 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; l the effectiveness of home visiting as a service delivery strategy; 9 the factors and strategies critical to designing home visitor programs; and l 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 vis- iting 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 objectives. We did not con- duct our own evaluation of the effectiveness or impact of these pro- grams or conduct a comparative analysis of effectiveness of different service delivery strategies, such as home-based versus center-based ser- vices. 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 con- ducted standardized telephone interviews to collect information about II Page 15 GAO/HRD-90-83Home Visiting Chapter 1 Introduction program objectives and structure. We judgmentally selected six US. pro- grams to provide diversity among program characteristics. Primary selection factors included programs . with different objectives, l 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 ser- vice 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 accor- dance with generally accepted government auditing standards. We did not, however, verify program cost information. Page 16 GAO/HRD-99-93Home Visiting Chapter 2 Rome Visiting Is an EstablishedService 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 Den- mark, home visiting is provided without charge to almost all families with young children. In the United States, home visiting is not univer- sally available. It is conducted on a project-by-project basis, by govern- mental 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 10 1st Congress, although it did not appro- priate funds. Despite such initiatives, we found only limited information exchange about home-visiting experiences across program lines. Home visiting is a common part of Western European maternity care.’ Home Visiting Home visitors may be midwives, but most often are specially trained Widespread in Europe nurses. Usually women are visited at home after a child’s birth (post- partum). 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. ‘C. Arden Miller, M.D., Maternal Health and Infant Survival, National Center for Clinical Infant Pro- grams, Washington, DC. (1987). Page 17 GAO/HRD90-83 Home Visiting Chapter 2 ; Home Visiting Is an Established Service Delivery Strategy With Multiple Objectives Table 2.1: Home Visiting in Nine Western European Countries Countrv Prenatal Postuartum Belaium Xa X Denmark Xa Xb Germany 0 0 Great Britain 0 X France 0 0 Ireland 0 X Netherlands X X Norwav 0 X Switzerland 0 X Legend: X Home visiting is provided at least once for all pregnant women or new mothers 0 Home visiting is provided under special circumstances, such as follow-up for a woman not attending prenatal clinic. Wnevenly implemented. bin municipalities that have home visrtors (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 Den- mark, 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 vis- itors. 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 regard- less of family income. It is an established part of preventive health ser- vices in national health care systems to which all citizens have access. Page 16 GAO/HRp@O&l Home Visiting chapter 2 Home Visiting Is an Established Service Delivery Strategy With Multiple Objectives Home visitors teach parents good health practices and provide preven- tive 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 pro- gram 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. Home visiting in the United States had a similar beginning to that in US. Home Visiting Great Britain and Denmark, but its development has been much less sys- Targeted to Low- tematic and uniform. Nevertheless, many local public and private agen- Income and Special ties provide home visiting. Compared to Europe, U.S. programs that provide home visiting are diverse in their goals and are likely to be Needs Families targeted to families with special needs, such as families with handi- capped 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 volun- teers became “Friendly Visitors” to poor families in Philadelphia, and the movement later spread to other large Eastern cities. In the early Page 19 GAO/HRD-90438Home Visiting Chapter 2 Home Visiting Is an Established !ikrvice Dellvery Strategy With Multiple Objectives 20th century, settlement houses2 began to send visiting nurses, teachers, and social workers into poor families’ homes to provide education, pre- ventive 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 Start3 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 chil- dren yearly. Targeted Programs With Many programs in the United States use home visiting to provide health, Diverse Goals 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 comprehen- sive picture of such programs.* In 1988, they surveyed over 4,500 pro- grams 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 pro- grams responding listed health as the primary focus. Overall, 43 percent “Community centers established in poor urban neighborhoods where trained workers tried to improve social conditions by providing such services as kindergartens and athletic clubs. “A national program providing comprehensive developmental services, including educational, health, and social services, primarily to low-income preschool children age 3 to 6 and their families. “Barbara Hanna Wasik and Richard N. Roberts, “Home Visiting Programs for Low-Income Families,” Family Resource Coalition Report, No. 1 (1989). Page 20 GAO/I-ID-90-83 Home Viiiting cllapter 2 Home Vi&Ing b an J,Wab&hed Service Delivery Strategy With Multiple Objectives 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 46 percent of programs targeted spe- cifically to low-income families. However, Head Start primarily serves children age 3 to 5 years. Federal and state governments support home visiting through many Funding for U.S. Home programs, with both one-time project funds and ongoing funding Visiting From Multiple sources. We could not determine the full extent of federal funding for Agencies home visiting, because federal managers we interviewed did not know the extent to which states were using federal monies to fund home vis- iting. 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 pro- grams. Formula grants are given to states, their subdivisions, or other recipients according to a formula (usually related to population) for con- tinuing activities not confined to a specific project. States often have to match federal formula grant funds with state-contributed funds. Page 21 GAO/IfRD30-33 Home Visiting i Chapter 2 Home Visiting Is an Established Service Delivery Strategy With Multiple Objectives Table 2.2: Federal Programs Used to Fund Home Viritor Proiect3 Agency Offlce Program We -Department of Health and Human Services -__. --.-.__---- Office of Human Development Head Start Home-Based Project grant Services/ Administration for Children, Head Start Youth, and Families Head Start Parent Child Centers Project grant Head Start Q;E;;hensive Child Development Project grant National Center on Child Abuse and g;;Xlttbuse and Neglect “Challenge” Formula grant Neglect National Center on Child Abuse and Child Abuse and Ne lect Research Project grant Neglect and Demonstration Eirants Public Health Service Maternal and Child Health and Maternal and Child Health Services Formula grant Resources Development Block Grant Maternal and Child Health and Special Projects of Re ional and Project grant Resources Development National Significance (1 PRANSJb Health Care Financing Administration -__-_--. Bureau of Program Operations Medicaid - Formula grantC Deoartment of Education Office of Special Education Programs Education of the Handicapped Act Formula grant Part B & H Programs Chapter 1 Handicapped Programd Formula grant Handicapped Children’s Early Project grant Education Program Wome 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. ‘Medicaid 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: l 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 Ser- vices (MCH) block grant? funds to expand to more sites a home-visiting program to prevent child abuse and neglect. “The 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 pro- vide assistance to children needing special health services. Page 22 GAO/IiltD30-33 Home Visiting Chapter 2 Home Visiting Is an Eetabliehed Service Delivery Strategy With Multiple Objectives l Missouri has funded a universal, educational home-visiting program, “Parents as Teachers,” using state education funds. l 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, developmentally delayed, or at risk of developmental delay. Also, most federal managers we con- tacted could not tell us the amount of funding their programs were pro- viding 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 visi- tors, 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 vis- iting 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 sup- ported 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 mater- ials on home visiting. However, two HHS-funded clearinghouses, the National Maternal and Child Health Clearinghouse and the Clearing- house on Child Abuse and Neglect Information, could not readily iden- tify resource materials on home visiting to improve maternal and child health outcomes or to prevent abuse and neglect. Page 23 GAO/HRD-90-83Home Visiting Chapter 2 Home Visiting Is an Established Service Delivery Strategy With Multiple Objectives Several recently enacted laws include provisions that may encourage New Impetus for home visiting. The Education of the Handicapped Act Amendments of Home Visiting From 1986, recent Medicaid prenatal care expansions, and the 1988 Child Recent Legislation 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. Public Law 99-457 May The Education of the Handicapped Act Amendments of 1986, Public Broaden Availability of Law 99-467, may further encourage home visiting. Through the addition of Part H, the statute authorized financial assistance to assist states in Home Visiting developing and implementing statewide, comprehensive early interven- tion services for developmentally delayed and at-risk infants and tod- dlers 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 eli- gible children. States must serve a core group of developmentally delayed children, but at their discretion can also serve children who are at risk of develop- mental 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. Chil- dren can be classed as “at risk” due to either environmental or biological risk factors. Environmental risk factors for children could include pov- erty, 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 pro- grams 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 99-467, agencies within the Department of Education and HHS cre- ated the Federal Interagency Coordinating Council (FICC).FICC'S mission is to develop specific action steps that promote a coordinated, inter- agency approach to sharing information and resources in five areas: (1) Page 24 GAO/HRD90-93 Home Visiting Chapter 2 Home Viaking Is an Eatabliehed Servlce Delivery Strategy With Multiple Objectives 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.) rrcc-supported activities include an annual Part- nerships 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 pro- ject 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 representa- tives of FICC also sponsored a February 1988 conference and subsequent publication, Family Support in the Home: Home Visiting Programs and P.L. 99-467, 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, Office of Director, Office of Special Special Education and Education Programs Rehabilitative Services Director, National Institute on Disability and Rehabilitation Research HHS Assistant Secretary, Office of Commissioner, Administration for Human Development Services Children, Youth and Families Commissioner, Administration on Developmental Disabilities Assistant Secretary for Health Director, 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 ;!Xr;;r for Maternal and Child Administrator, Health Care Financina Administration Page 26 GAO/HRD-9083 Home Visiting Chapter 2 Home Visiting Ia an Established Service D&very Strategy With Multiple Objectives States Are Using Medicaid Medicaid has become a more significant source of funding for pre- and to Fund Home Visiting 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 chil- dren, primarily by severing the link between eligibility for Medicaid and Aid to Families With Dependent Children (AFDC).~ 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 ser- vices 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’ Associa- tion and the National Commission to Prevent Infant Mortality, as of Feb- ruary 1990, ‘24 states7 were using Medicaid to pay pre- and/or postnatal care providers for home visiting. “Medicaid 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 ($7,966) in California. The 1989 federal poverty level for a family of three was $10,060. 7Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, Idaho, Kansas, Maryland, Michigan, Minnesota, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Penn- sylvania, Tennessee, Utah, Vermont, Virginia, and Washington. Page 26 GAO/HRD-90-83Home Visiting Chapter 2 Home Vldting In an Eetabllehed Service Dellvery Strategy With Multiple Objectivea Home Visiting Is The Child Abuse Prevention, Adoption, and Family Services Act of 1988 Encouraged to Prevent recognized home visiting as an appropriate strategy for preventing child abuse and neglect. This act focused federal efforts to aid states and Child Abuse and Neglect 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 Several legislative proposals that addressed home visiting were intro- Visiting in Recent duced in the 1Olst Congress: Legislative Proposals . 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. 9 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. l 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. 9 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 Mor- tality Amendments of 1990 (H.R. 3931) proposed that prenatal home- visiting services for high-risk pregnant women and postpartum home- visiting services for high-risk infants up to age 1 be made optional Medi- caid services. The Congressional Budget Office estimated that if home visiting was made an optional Medicaid service, as proposed in H.R. 2924, the addi- tional federal Medicaid cost would be $95 million over a 5-year period for fiscal years 1990-94. If the services were mandatory, as was pro- posed in H,R. 1573, the estimated additional 5-year federal cost could go up to $625 million. Page 27 GAO/HRD-90-83Home Visiting chapter 2 Home Vl&lng h an Ewabllahed Service Delivery Strategy With Multiple Objectivea None of this legislation was passed as introduced, as of June 1990. However, the Congress did authorize, through the Omnibus Budget Rec- onciliation Act of 1989 (Public Law 101-239), new home-visiting demon- stration projects to be funded through a set-aside from the MCH block grant when its funding level exceeds $600 million (currently at $66 1 million). Page 28 GAO/I-lItD-90-63 Home Visiting fiome-Visiting Evaluations Demonstrate Benefits, but SomeQuestionsRemah 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 par- ticularly 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. Evaluations of early intervention programs that used home visiting Program Evaluations show that this strategy can be associated with a variety of improved Show Benefits of outcomes for program participants- improved birth outcomes, better Home Visiting 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: l 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.’ . Low-income mothers visited in Michigan gave birth to babies with sig- nificantly improved birthweight and health at birth, compared to both ‘Henry C. Heins, Jr. and others, “Social Support in Improving Perinatal Outcome: The Resource Mothers Program,” &3etrics and Gynecology, Vol. 70, No. 2 (Aug. 1987). Page 29 GAO/HRD90-83 Home Visiting Chapter 3 Home-Visiting Evaluations Demonstrate Benefits, but SomeQnestions Remain their previous pregnancies and to a control group with similar demo- graphic characteristics2 . 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.” . For several home-visiting projects, participants had a lower reported incidence of child abuse and neglect than that found in similar families.4 Children at risk of developmental delay have also benefited from ser- vices 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.” For example: . Fewer low birthweight children in a Florida program needed additional developmental services after graduating from a randomly assigned 2- year home-visiting program compared to children who received no services.” l Three years after the program ended, children in Jamaica who were home visited to help them overcome the effects of malnutrition had sig- nificantly higher IQ scores than malnourished children with similar medical and demographic characteristics who had not received services7 Other programs have also found significant improvements in the cogni- tive ability of rural and inner-city children who had been provided with “Jeffrey P. Mayer, “Evaluation of Maternal and Child Health Community Nursing Services: Applica- tion of Two Quasi-Experimental Designs,” Health Action Papers, Vol. 2 (198s). “Charles P. Larson, “Efficacy of Prenatal and Postpartum Home Visits on Child Health and Develop- ment,” Pediatrics, Vol. 66, No. 2 (Aug. 1980). 4U.S. Congress, Office of Technology Assessment, Healthy Children: Investing in the Future, OI’A-H- 346 (Washington, DC.: U.S. Government Printing Office, Feb. 1988); Deborah Daro, Confronting Child Abuse: Research for Effective Program Design, The Free Press, New York, 1988. “Tiffany M. Field and others, “Teenage, Lower-Class, Black Mothers and Their Preterm Infants: An Intervention and Developmental Follow-up,” Child Development, Vol. 61 (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. 64, No. 2 (Apr. 1984). “Michael B. Resnick and others, “Developmental Intervention for Low Birth Weight Infants: Improved Early Developmental Outcomes,” Pediatrics, Vol. 80, No. 1 (July 1987). 7Sally Grantham-McGregor and others, “Development of Severely Malnourished Children Who Received Psychosocial Stimulation: Six Year Follow-up,” Pediatrics, Vol. 79, No. 2 (Feb. 1987). Page 30 GAO/HRD-90-93Home Visiting chapter 3 Home-VFsitingEvaluations Demonstrate Benefits, but SomeQuestions Remain preschool services through home visiting, compared to children who were not provided with such services.R Benefits to Families Can The full effects of early intervention programs using home visiting as Persist Over Time 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 eval- uations that had provided both center- and home-based services. From 1962 to 1967, the High/Scope Perry Preschool Program, in Ypsi- lanti, Michigan, provided both weekly home visits for the parents of low-income, 3- and 4-year-olds and comprehensive center-based pre- school 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 sig- nificantly higher on tests of intellectual ability after 1 year in the pro- gram and did better on standardized testing through the middle grades, than 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.” (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.10 sDonna M. Bryant and Craig T. Ramey, “An Analysis of the Effectiveness of Early Intervention Pro- grams 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 Pre- school Students ln a Home-Based Early Childhood Education Program,” Journal of Educational Research Vol76, No. 1 (Oct. 1982). --) “Lawrence 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 PF- chologlcal Association, Washington, D.C. (1988). “‘Ron Hasklns, ‘Beyond Metaphor: The Efficacy of Early Childhood Education,” American Psycholo- gist, Vol44, No. 2 (Feb. 1989). Page 31 GAO/HRD-90-83Home Visiting Chapter 3 Home-Vieiting Evaluations Demonstrate Benefita, but SomeQuestions Remain and Home-Visiting Servkeo Were More 100 Percent of Studants Successful in Later Years Received Services Did Not Receive Services Note: Results show comparative outcomes at age 19 for High/Scope Perry Preschool children com- pared 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 chil- dren as better adapted socially and needing fewer remedial school ser- vices than the control children.11 ’ ‘Victoria Seitz and others, “Effects of Family Support Intervention: A Ten-Year Follow-up,” Child Development, Vol. 56 (1986). Page 32 GAO/HRD-99-33Home Visiting Chapter 3 HomeWsiting Evaluations Demonstrate Beneflts, but SomeQuestions Remain Intense Programs Have Evaluations of early intervention programs using home visiting and More Marked Effects varying in service intensity-the amount of program contact with cli- ents over time-found that more intense programs are generally more effective. An evaluation of a program in Jamaica that provided home-visiting ser- vices 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. l2 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 effec- tiveness 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.13 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 fami- lies 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 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.14(See fig. 3.2.) i2Christine Powell and Sally Grantham-McGregor, “Home Visiting of Varying Frequency and Child Development,” Pediatrics, Vol. 84, No. 1 (July 1989). i%onna 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). i4Denald 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, DC. (1988). Page 33 GAO/HRD90-83 Home Visiting Chapter 3 Home-Visiting Evaluations Demonstrate Benefits, but SomeQuestions Remain Figure 3.2: Type and Amount of Services Affect Later Reading Ability 60 Poroont of 2nd Gradam wlth Reading Problems Chlldmn of Chlldmn of Losa Educated Mom Educated Mothem Mothem Home Visiting and Center Services Every 3-4 Weeks Home Visiting and Center Services Every 6 Weeks Use of Drop-In Center Only No Services 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, Wash- Ington, DC. (1988). Whether one early intervention strategy is more effective than another ResearchShows Home is difficult to determine from the literature because few programs were Visiting Compared to developed and operated as part of a controlled experiment or quasi- Other Strategies Is experiment. Many programs demonstrating benefits to clients delivered both in-home and center-based services, but did not try to determine Promising, but More which had the greater impact or which was the most cost-effective. We Study Is Needed 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 Page 34 GAO/liRB9O-33 Home Visiting Chapter 3 Home-Vitdtlng ihluations Demonstrate Renellts, but flame Queetione Remain 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 addi- tion 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, com- pared to the women who were not visited, included the following: l Higher birthweight babies born to teen mothers and smokers. l Fewer kidney infections during pregnancy. . Fewer verified cases of child abuse and neglect. l Four years later, more months of employment, fewer subsequent pregnancies, and postponed birth of second child.16 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 formal service providers, such as abusive families. Home-Based Head Start is an example of a pro- gram 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.16 ‘“David 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 Randonuzed Trial of Nurse Home Visitation,” Pediat- rics, Vol. 78, No. 1 (July 1986); David L. Olds and others, “Improving the Life-Course Development of !%&lly Disadvantaged Mothers: A Randomized Trial of Nurse Home Visitation,” American Journal of Public Health, Vol. 78, No. 11 (Nov. 1988). “‘John M. Love and others, Study of the Home-Based Option in Head Start, RMC Research Corpora- tion, 1988. Page 35 GAO/lEWMO-33Home Visiting Chapter 8 HomeVisiting Evduations Demonstrate Benefits, but SomeQuestions Remain Evaluations that analyze home visiting’s costs and benefits, while few in Limited Research number, have shown that programs incorporating home visiting as a ser- Shows Home Visiting vice delivery strategy can prevent families from needing later, more Can Produce Cost costly public supportive services. Cost savings become more obvious when examined by longitudinal studies or when initial costs for alter- Savings nate solutions are high. Whether home-based services are more expen- sive 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 esti- mates of immediate or future cost savings. Yet the results of these studies are compelling. They represent findings from studies with rig- orous 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.17 According to the program evaluators, taxpayers saved approximately $5,000 in special education, $3,000 in crime, and $16,000 in welfare expenditures per par- ticipant. More Perry Preschool graduates enrolled in college or other advanced training, which added $1,000 per preschool participant’s 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 con- ducted 10 years later. Families in the program showed a slow but steady rise in financial independence, which translated into reduced subse- quent welfare costs. No significant differences were found for girls, but each participating boy required, on average, $1,100 less in school reme- dial services than boys in families who had not received services.lH 17Lawrence J. Schweinhart and David B. Weikart, “The High/Scope Perry Preschool Program,” in 14 Ounces of Prevention: A Casebook for Practitioners. ‘*Victoria Seitz and others, “Effects of Family Support Intervention: A Ten-Year Follow-up,” Child Development. Page 36 GAO/HRD-90-83Home Visiting chapter 3 Home-Vlsifing Evaluations Demonstrate BenefIta, but SomeQuestions Remain Few Comparisons of Cost-effectiveness analysis evaluates the cost of producing a particular Cost-Effectiveness outcome using alternative strategies. But the most effective or least costly alternative may not always be the most cost-effective.‘” 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 visi- tors 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 stan- dard set of conditions. Families of early-discharge infants received indi- vidualized instruction, counseling, and home visits, and were allowed to call a hospital-based nurse specialist with any questions for 18 monthszo 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 $47,620 compared to $64,940 for the control group. The home-visited infants also experi- enced 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. “Henry M. Levin, Cost-Effectiveness: A Primer, New Perspectives in Evaluation, Volume 4, Sage Publications (1983). “‘Dorothy 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). Page 37 GAO/HRD-90-83Home Visiting Chapter 3 Iiome-vieitiug Evaluationa Demonstrate Benefits, but SomeQuestions Remain 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 pro- fessional 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 60 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 serviceszl However, in this case, combining home visiting with center-based social work services almost tripled the cost per client (from $93 to $266 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 super- vised by the 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. 21Joseph P. Hornick and Margaret E. Clarke, “A Cost-Effectiveness Evaluation of Lay Therapy Treat- ment for Child Abusing and High Risk Parents,” Child Abuse and Neglect, Vol. 10 (1986). Page 38 GAO/HRD-M Home Visiting Chapter 4 Poor Program DesignCan Limit Benefits of HomeVisiting Not all programs using home visiting to deliver services have been suc- cessful. 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 evalua- tions 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. Some evaluations of programs using home visitors that failed to achieve Poor Program desired outcomes have identified certain causes for the failure. These Outcomes Linked to include Design Weaknesses . 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.’ Child and Family Resource The Child and Family Resource Program, a federally funded demonstra- Program tion 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 1 l-site, home- and center-based project was designed to strengthen families economi- cally 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 ‘For 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 Neg- lect, and Health Care Utilization,” Pediatrics, Vol. 66, No. 2 (Aug. 1980); Violet H. Barkauskas, “Effectiveness of Public Health Nurse Home Visits to Prlmarous Mothers and Their Infants,” Amer- ican Journal of Public Health, Vol. 73, No. 6 (May 1983); Richard P. Barth and others, “Preveni child Abuse: An Experimental Evaluation of the Child Parent Enrichment Project,” Journal of Prl- mary Prevention, Vol. 8, No. 4 (Summer 1988). Page 39 GAO/HRD90-83 Home Visiting , Chapter 4 Poor Program Design Can Limit Benefits of Home Visiting 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 weak- nesses 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 par- ents 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 visi- tors 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 success2 Boston’s Healthy Baby The HHS Inspector General reported in 1989 that Boston’s Healthy Baby Program 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 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 fac- tors among program participants, was providing services late in preg- nancy 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 out- comes, 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 BRobert 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 Fran&e H. Jacobs, ed., Aldine de Gruyter, New York (1988). Page 40 GAO/HRD-90-83Home Visiting chapter 4 Poor Program Design Can L&nit Beneflt8 of HomeVisiting families with multiple problems such as inadequate housing and sub- stance abuse, was located in an agency with little experience in helping such families. The program staff also had not developed effective link- ages with prenatal care providers and other social service agencies3 Rural Alabama Pregnancy The Rural Alabama Pregnancy and Infant Health Program, one of five and Infant Health Program 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 pro- gram 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 develop- ment, compared to a demographically similar group of children who were not visited.4 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 of information to teach the clients. Finally, program evalu- ators concluded that the home visitors needed more supervision.” Prenatal/Early Infancy The Prenatal/Early Infancy Project in Elmira, New York, demonstrated Project 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 “Office of Inspector General, Department of Health and Human Services, Evaluation of the Boston Healthy Baby Program (July 1989). 4J.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. “Mary Lamer, “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; MC. 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. Page 41 GAO/HRD-90-33Home Visiting Chapter 4 Poor Program Design Can Limit Beneflts of Home Vidng 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 ser- vices, 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 finan- cial support, and location within the local health department all contrib- uted 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 unani- mous 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 ser- vices should be provided to a larger group of pregnant women, which may be diluting the overall impact of the formerly targeted, high- intensity services. Our analysis of these and other evaluations, consultation with experts, Critical Components and interviews with federal, state, and local program officials point to for Program Design 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 Page 42 GAO/HRD-90-83Home Visiting Chapter 4 Poor Program De&n Can Limit Ben&t8 of Home VWlng 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 ser- vices 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. Page 43 GAO/HRD-90-M Home Visiting Chapter 6 A Framework for DesigningProgramsThat 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 oper- ated 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 6.1 for high- lights of differences.) Despite these differences, these programs illus- trate the importance of certain design characteristics. In general, these programs’ managers l developed clear objectives, focusing and managing their operations accordingly; l 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 out- look 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 con- stituent parts, shown in figure 6.1, include clear objectives, structured service delivery procedures, integration into the local service provider network, and secure funding over time. Page 44 GAO/HRD9@83Home Visiting Chapter 5 AFramework for Dedgning ProgramsThat Use HomeVbitlng Table 5.1: Characteristics of United States and European Programs GAO Visited Proaram name Area served Pooulation served Tvoe of home visitop United States Resource Mothers for Pregnant Teens, South Rural Pregnant teens, teen mothers Paraprofessional Carolina Center for Development, Education, and Urban Developmentally delayed children Professional Nutrition (CEDEN), Austin, Texas Urban Pregnant low-income women Professional Southern Seven Health Department, Rural Pregnant teens Professional Southern Illinois Maternal and Child Health Advocate Urban Pregnant women; mothers with high- Paraprofessional Proaram, Detroit, Michiaan risk newborns Urban Pregnant teens; teen mothers Paraprofessional Europe Great Britain Health Visitor Nationwide All newborns Professional Denmark Infant Health Visitor Nationwide Newbornsb Professional 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 oroaram continuitv Page 45 GAO/HRD9O-33Home Visiting r Chapter 5 A Framework for Dedgning ProgramsThat Use Home Vieitlng Clear, precise, and realistic objectives are crucial for enabling programs Clear Objectives as a using home visiting to sustain program focus among the home visitor Cornerstone staff and to deliver relevant services to an appropriate client popula- tion 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 moni- toring progress. Objectives, Target Objectives, target populations, and services are logically interconnected Pnnl11nt.i * v&a ms, and Services LI.uv.v* program elements. As program managers develop objectives in response to problems, such as infant mortality or child abuse, they also begin to Are Interd ependent 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 develop- ment as a pressing community problem. To address children’s develop- mental 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 ser- vices. 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 Chi- cago 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. FLAPPrefers 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 Page 46 GAO/HRD90-83 Home Visiting Chapter 5 A Framework for Designing ProgramsThat Use Home Visiting 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 Clear objectives also serve as the basis for determining outcome mea- Management Tool sures used in program monitoring and evaluation. For example, if a pro- gram’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 cog- nitive development to measure progress toward its objectives of pre- venting or reversing developmental delay. It also compares entry and exit statistics for well-child checkups, immunizations, illness and hospi- talization rates, and the number of children with medical coverage to measure progress toward objectives related to improving the health of program children. WP also measures progress quarterly by determining whether its cli- ents 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 informa- tion to managers, At the time of our review, preliminary results from an external evalua- tion of CEDEN showed that the program was effective in reducing devel- opmental delays in client children. Further, CEDEN'S executive director said that preliminary results suggest that the program should Page 47 GAO/HRD-90-93Home Visiting Chapter 5 A Framework for Designing ProgramsThat Use Home Visiting . 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 l 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 suc- cessful 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 pro- gram 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 compo- nents, although they differed in the level of sophistication. None, how- ever, had completed evaluations that compared costs to relative benefits. Therefore, program managers could not clearly document the cost savings that each believed they were achieving. A “structured” service delivery approach-one that has defined activi- Structured Program ties and a sequenced plan for instruction with a detailed curriculum or Delivered by Skilled protocol-serves as a blueprint for guiding home visitor services. The Home Visitors 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. Pro- grams 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 exami- nations, 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. Page 48 GAO/HRD-90-83Home Visiting Chapter 6 AFramework for Designing ProgramnThat UeeHome Visiting Structured Service Structuring services with a written curriculum can be particularly Delivery 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 l 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 US. 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 preg- nancy and age of the baby. The home visitor can 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 sup- port, 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 visi- tors 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 visi- tors, 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. Page 49 GAO/HID-BO-83 Home Visiting chapter6 A Fhmewvrk for Designing ProgramaThat use Home visiting Match Between Program The experience of home-visiting experts reinforces what appears to be Services and Home Visitor intuitively true: programs delivering specialized, technical services need i21,:11#l to use educated and skilled home visitors. British health visitors, for olu113 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 fac- tors 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 individual- ized 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. Training and Supervision Programs we visited using paraprofessional home visitors generally pro- Tailored to Home Visitor vided more training- both before (preservice) and after (in-service) home visiting began-than did programs using professionals. Detroit’s Skills Health Advocate program provided a full-time, preservice, g-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 Page SO GAO/HRD-90-83Home Vi&ing Chapter 6 AFramework for Designing ProgrammThat Use Home VMing Configuration of Early Prenatal Care (EPIC) project in Providence, Rhode Island, used nurses from the Visiting Nurse Association, Inc., with bach- elor 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 ori- ented 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 6 1 weeks of home visitor class- room 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-regard- less of program objectives- often talked about the need to be ade- quately 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 supervi- sors believed that supervisors play a critical role 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 experi- enced early difficulty with its choice of home visitors-former AFJX mothers. Program managers and supervisors found that these home visi- tors experienced difficulties adjusting to their new responsibilities and required more support and supervision than initially anticipated. Detroit’s Health Advocate supervisors accompanied their paraprofes- sional home visitors at least once a month, reviewing each case with the visitor before the next visit. In contrast, British home visitors are Page 51 GAO/HRD-SO-83 Home Vidting Chapter 5 A Pnuneworlc for Dedgdng ProgramsThat Use Home Visiting 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. Home visitors can help clients overcome some access-to-service Strong Community problems by coordinating or providing needed services. In their coordi- Ties in a Supportive nation role, home visitors act as case managers for their clients by Agency 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 Home visitors need to be familiar with the community’s health, educa- Programs tion, and social services network and must develop relationships with individual providers in order to link clients with needed community ser- vices. 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. Detroit’s Health Advocate program developed links to community resources by participating in provider networks. The program’s man- agers 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 pro- mote 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 Page 62 GAO/HRD-90-33Home Visiting Chapter 5 A Fkameworkfor Designing Programa mat Use Home Visiting system of about 200 agencies offering such services. CEDEN'S home visi- tors 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 man- agers, 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. US. 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 US. 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 Programs that used home visiting often had mixed social, health, and Supportive Agency child development objectives. These programs are enhanced when housed in agencies supportive of the delivery of multifaceted services. We visited programs with different types of agency affiliation-admin- istered by a social service agency within a health department, a univer- sity, or an agency experienced in delivering family services addressing various problems. All of these agencies were supportive of the pro- grams’ 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 Page 53 GAO/HBD90-83 HomeVi&ing chapter 5 A Prameworlt for Designing Prom That Use Home Vidting enhance the home-visiting program’s ability to meet both its social sup- port 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 depart- ment’s social work director. The health department provides such ser- vices 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 WP. This private, nonprofit organization develops and operates pro- grams for pregnant teenagers and coordinates with other agencies to deliver services that they cannot directly provide. Since Catholic Chari- ties has expertise in delivering services related to WP’S goals, it can advise and assist RAPP on how to best achieve program goals. Home Visiting Does Not Regardless of how well services are coordinated, programs providing Substitute for Lack of supportive services through home visiting do not substitute for some gaps in community services. A clear example is prenatal care. Women Services who obtain inadequate prenatal care are less likely to have a healthy birth outcome than women who obtain adequate care. While the Insti- tute 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 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 Carbon- dale to deliver their babies. Although, for legal reasons, Southern Seven home visitors are not allowed to transport women in labor, they make Page 64 GAO/HRD-90-33Home Visiting Chapter 6 A Prameworlcfor Designing Prow That Use Home Visiting 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. Developing strategies to secure ongoing funding strengthens home- Ongoing Funding for visiting services by giving programs time to establish themselves in the Program Permanency 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 opportu- nity to do so. But three of the six U.S. programs we visited were devel- oped as time-limited projects,’ 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 Developing, implementing, and evaluating the impact of home-visiting and Demonstrate services while maintaining continuity of services takes several years. Three-year or shorter funding cycles put considerable pressure on pro- Effectiveness grams 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. At the beginning, the program’s home visitors, who were AFDC recipi- ents, were given supplementary Volunteers in Service to America ‘EPIC, Resource Mothers, Health Advocates. Page 66 GAO/HRLMO433Home Visiting , Ckapt43r6 A Framework for De&nix@ PIQ#~ That , Use Home Wdting (VISTA)~ 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. Con- sequently, the program lost clients because some, having established a rapport with the first home visitor, did not want to continue the pro- gram 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 demon- strated 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)3grant. 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 SPRANSgrant, 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 pro- gram services in June 1989. The program was planned as a research project to see if nurse home visiting between weeks 20 and 30 of preg- nancy could improve birth outcomes. Although no immediate state com- mitment 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 determine the impact of the home visits on their clients. In the meantime, the program has been par- tially replicated by some local health departments that saw its benefits “VISTA provides small stipends to full-time volunteers who work for governmental or nonprofit agen- cies on projects to improve the lives of the poor. ‘3Theseprojects are funded by a federal set-aside of between 10 and 16 percent of the MCH block grant appropriation. Page 66 GAO/HRDBO-g3Home Visiting chapter 5 A Framework for Designing Prognuw~That Use Home Visiting 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 lo-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 prov- iders, and with clients. CEDEN is well known and well respected by mem- bers of the community and other area service providers. As a result, many CEDEN clients are referred from diverse sources-other social ser- vice 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 The U.S. programs we visited that were able to maintain continuous to Maintain Services 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 inter- vention is so diversified. CEDEN, a community-based agency, has obtained, in addition to federal, state, and local funds, funding from pri- vate 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. Page 57 GAO/HRD9O433Home Visiting Chapter 5 A Framework for Designing Programs That Use Home Visiting 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 pri- vate 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 com- munity services and was able to successfully replace demonstration pro- ject funding with more ongoing state-administered funds, such as the MCH block grant and other state funds. Page 68 GAO/H&D!MJ-33Home Visiting Chapter 6 Conclusions, l&commendations, and Agency Comments Home visiting is a technique widely used in both the United States and Conclusions Europe to provide families with preventive, in-home services. Home vis- itors provide a broad range of services, including home-based assess- ments, 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 ser- vices, 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 Euro- pean countries we visited, no single federal home-visiting program or federal focal point for home visiting exists; rather, the federal govern- ment 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. l Home visiting can be an effective strategy for reaching at-risk fami- lies 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. Page 59 GAO/EJlUb99-33Home Visiting chapter 6 ~nchsions, &commendations, and Agency Commenta Given limited public resources, we believe that home visiting should be targeted to specific populations most likely to benefit from these person- alized services. These might include young, poor mothers, particularly single mothers; they have clearly benefited from past programs. Chil- dren 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 univer- sally 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 fami- lies 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 characteris- tics that strengthen program design and implementation. The benefits of home visiting depend on certain program design charac- teristics. 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 pro- gram 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 devel- opment services, need more structure and more educated, skilled visi- tors than programs delivering information, support, and referrals to other providers. Home visitors need solid pre- and in-service training Page 60 GAO/HRB9O-g3Home Visiting Chapter 6 Conclusions, Recommendations,and Agency Comments and close supervision from professionals. This program support is par- ticularly 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 sus- tained 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 institu- tions 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, pro- grams using home visiting need to be located within agencies or depart- ments 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 effec- tive case managers. l 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 govern- ment, 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 legisla- tion. The Omnibus Budget Reconciliation Act of 1989 authorized a new Page 61 GAO/HRD-90-83Home Visiting Chapter 6 Conclusions, Recommendations,and Agency Comments 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 mil- lion (currently at $661 million). Twenty-four states have used the Con- gress’ 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. 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 mil- lion 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 collabo- rating with states and localities and helping them develop programs for providing early intervention services to children. The Federal Inter- agency 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 intergovern- mental collaboration for family support programs, FICCappears to be a ready focal point for further home-visiting initiatives, especially infor- mation exchange. Other federal mechanisms that can support home vis- iting 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 mater- ials, 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 pro- gram practice and fill information voids. This might include stepped-up federal efforts to encourage the integration of home visiting into Page 62 GAO/HRD-99-93Home Visiting Chapter 6 Conclusions, Recommendations,and Agency Cmunent8 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 vis- iting, 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. The Congress has expressed its interest in home visiting as a strategy Matter for for bolstering at-risk families. In view of the demonstrated benefits and Congressional cost savings associated with home visiting, the Congress should consider Consideration establishing a new optional Medicaid benefit: as prescribed by a physi- cian 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 explic- itly covered Medicaid service to improve birth outcomes will encourage states to provide ongoing funding for prenatal and postpartum home visiting. We recommend that the Secretaries of HHS and Education require feder- Recommendations ally funded programs that use home visiting to incorporate the fol- lowing 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. Page 63 GAO/H&D90-83 Home Visiting Chapter 6 conclusion, bxonunendations, and Agency Comments We further recommend that the Secretaries of HHS and Education: l make existing materials on home visiting more widely available through established clearinghouses, conferences, and communications with states and grantees. l 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) incor- porate home visiting permanently into local maternal and child health and welfare service systems, and (3) replicate models that have demon- strated their efficacy. . 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 devel- oping program services and program evaluations and (2) supporting the development of a core curriculum for home-visitor training. HHS and the Department of Education generally concurred with our con- Agency Comments clusions and recommendations. They supported our characterization of home visiting as a strategy to provide early intervention services to cer- tain targeted populations, and not a stand-alone program. The depart- ments 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 mecha- nisms, 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 depart- mental programs. Although Education provided examples where some of the design elements are already incorporated as program funding cri- teria, 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. Page 64 GAO/HRD-90-83Home Visiting chapter 6 Conclusions, Recommendations,and Agency Comments 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 consid- ered when designing and managing programs that incorporate home vis- iting. 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 popula- tions or the nature and intensity of services-may warrant further research and evaluation. Both HHS and Education agreed with our recommendation to give pri- ority to federal demonstration projects that meet the multiple needs of target populations and replicate models of proven efficacy. But both were hesitant to give priority to home visiting over other early interven- tion 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 sus- tained basis, rather than continuing to fund short-term, finite, experi- mental 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 chil- dren. As discussed on pages 24-25, FICC has already conducted high-pro- file 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 vis- iting as an optional service was necessary. It pointed out, as did we on page 26, that states essentially have that option, since some types of home visiting are presently covered under different categories of ser- vice. But we believe that explicitly making home visiting an optional Page 65 GAO/HR.D-W-33Home Visiting Chapter 6 Conclusiona, Recommendatlone,and Agency Comments covered service would send a clear message to the states about the effi- cacy 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 Euro- pean 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 common- alities 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 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 pro- grams 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. Page 66 GAO/IUtB3O-63 Home Visiting Y Page 07 GAO/HRJMW33Home Visiting Appendix I Descriptionof the Eight Home-Visiting ProgramsGAO 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. l A services and activities section, which describes the services provided in the home and the type of service provider. l A results section, which describes evaluation efforts and results. l A section describing the program’s funding, costs, and benefits. l A section describing officials’ views about the program’s future. Center for Development, Education, and Nutrition Table 1.1: 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 enrollina 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 Page 68 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight Home-Visiting ProrpgmsGAO Visited center that provides educational and human services to children with developmental deficiencies and to their parents. 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 (6) 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 develop- ment. 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 back- grounds 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 Services are delivered through three programs: (1) the Parent-Child Pro- Activities gram, 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 pro- grams 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 ser- vice delivery method for Parent-Child Program services. The home parent educators must have college degrees, preferably have 3 years’ Page 69 GAO/HRD-90433Home Visiting Appendix I Description of the Eight HomeVi&ing I’rogmms GAO VI&ed experience in child development, and are expected to establish a rapport with their clients. They receive 2 weeks of 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 develop- ment, and psychology. After enrolling in the program, each family receives 24 to 34 consecu- tive 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 pro- viding health and nutrition information and nutritional and diet anal- yses, 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 deter- mine 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 per- form 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 participa- tion 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, 46 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 Page 70 GAO/HRD-30-33Home Vidng Appendix I Description of the Eight Home-Vi&ing Progmms GAO Vidted 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. Program Funding, Costs, During 1989, CEDEN received about $441,000 from several sources, and Benefits including about $266,000 from federal, state, and local governments; $68,000 from nongovernmental grants; and $101,000 from foundations. The cost of an average CEDEN home intervention in 1984-86, the most current year for which information was available, was about $1,096 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 $86,000 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 260 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. Page 71 GAO/IiRD90-33 Home Vi&ing Appendix I kxwrlption of the Eight Home-Visiting ProgramsGAO Vi&e-d &source Mothers for Pregnant Teens Table 1.2: Program Profile: Resource Mothers for Pregnant Teen8 Geographical areas served: 16 rural counties in South Carolina Goals/objectives: Reduce infant mortality and low birthweight Administrative aaencv: State and local health departments Service delivery method: Home visitinq Target population: Pregnant teens and teen mothers Number and timing of intervention: Monthly l-hour prenatal visits; l-hour bimonthlv postnatal visit up to aqe one Home visitor qualifications: High school diploma; ability to establish a raooort Supervisorv characteristics: Master’s dearee in social work Number of home visitors: 16 Clients served: 1);;; 1,300 from July 1986 through February Fiscal year 1989 fundinq: $521,351 Evaluation results: Reduced the number of low birthweight babies: increased the receipt of orenatal 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 adoles- cents and to improve the health and parenting activities of those adoles- cents. The program initially targeted teenagers 17 years of age and under, pregnant with their first baby. The program now serves l&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 Page 72 GAO/HIUMMM3 Home Visiting Appendix I Description of the JSightHome-Visiting Pro@vunsGAO Visited 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 The Resource Mothers program has many objectives that address the Activities 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. 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 nutri- tion, 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. Page 73 GAO/HRD-90-93Home Visiting . Appendix I Description of the Eight Home-Vi&ing ProrpamsGAO Visited 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. 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 per- cent not becoming pregnant for 1 year after giving birth. The program did not meet its objectives of 85 percent of the teens gaining the recom- mended weight during pregnancy, 90 percent enrolling in family plan- ning 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. Page 74 GAO/HRD9O-S3 Home Vbiting .- Appendix I Deecdption of the Eight Home-Visiting PcorplamsGAO Vieited Program Funding, costs, The program was originally funded by a Robert Wood Johnson Founda- and Benefits tion 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 Sig- nificance 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 con- tinue 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 eventu- ally operate statewide. Page 75 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight Home-Visiting PcogramsGAO Visited Roseland/Altgeld Adolescent Parent Project Table 1.3: 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 1 l-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-l 75 per year Fiscal year 1988 funding: $327,271 Evaluation results: No formal evaluation Background The Roseland/Altgeld Adolescent Parent Project in Chicago serves preg- nant and parenting teenagers and their babies. RAPP’S goal is to decrease the negative social, health, and economic 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 mor- tality and morbidity, child abuse and neglect, and other negative conse- quences associated with adolescent pregnancies; (2) increasing healthy family functioning and well-baby care; (3) providing access to the com- munity’s resources by networking and participating in community orga- nizations 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 adoles- cents. Its goal is to decrease infant mortality, child abuse and neglect, and teen pregnancies by sponsoring projects such as WP. Page 78 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight Home-Visiting Programs GAO Visited Catholic Charities formed RAPP to serve pregnant and parenting females, age 1 l-20, in the Roseland and Altgeld Gardens communities. Roseland is a neighborhood of older single-family dwellings with high unemploy- ment. 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 preg- nancy rates and poor economic conditions. Over 25 percent of Rose- land’s teenage girls became mothers, and one-third of the births in Altgeld are to teen mothers. Program Services and The home visitors provide a variety of services either in the home or in Activities group meetings. These include (1) teaching well-baby care, (2) adminis- tering the Denver Developmental Screening Test to identify develop- mental 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 l-week orientation about the program’s goals, objectives, and 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 manage- ment, 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 inap- propriate because unexpected problems may arise, and the home visi- tors 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 preg- nancy 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 Page 77 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight Home-Visiting Rogmns GAO Visited 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 offi- cials 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, From 1986 to 1989, RAPP received funding from the state of Illinois, and Benefits 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 population and to hire aides to take care of the babies during group meetings. Page 78 GAO/HRD-90-33Home Visiting Appendix I Description of the Eight Home-Visiting Programs GAO Visited Southern Seven Health Department Program: Parents Too Soon and the Ounce of Prevention Components Seven Health Department Program (Parents Too Soon and the Ounce of Geographical areas served: Seven rural counties in southern Illinois Prevention Components) 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 deliverv method: Home visitina. workshoos Tarqet population: Prennant and parentina teens, aqes lo-20 Number and timing of intervention: Parents Too Soon corn onent-monthly prenatal visits, and at f 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 aae 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 proaram participants than nonparticipants Background The Southern Seven Health Department Program, which provides ser- vices in seven southern Illinois counties, focuses on (1) reducing the neg- ative 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. Page 79 GAO/HRLMW33Home Visiting Appendix I Description of the Eight HomeJisiting PIV#JWIMGAO Visited 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 sep- arate staff. The Parents Too Soon (PTS) component is a state program that attempts to deter teenage pregnancy and lessen the negative conse- quences 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 out- comes for teens enrolled in the program. Program Services and To accomplish the program’s objectives, the home visitors provide a Activities variety of services. These include (1) teaching prenatal and well-baby care, (2) ensuring that the client has a medical provider and transporta- tion to get there, (3) providing information on family planning, (4) coun- seling 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 whose primary responsibility is to help teens to remain in school. New home visitors receive 1 to 2 weeks of orientation about the pro- gram. The FTSstaff are not required to attend in-service training; how- ever, 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 assess- ment to determine the client’s needs and develops a service delivery strategy to ensure that those needs are met. When the client is near Page 80 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight HomeVi&ing I’ro~ama GAO Vieited delivery, she is transferred to the Ounce program and another assess- ment 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 curric- ulum that allowed flexibility. The frequency of home visits varies by program component and the client’s needs. However, a general rule is that the PI% staff see their cli- ents 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 compo- nent, 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 birth- weight infants, compared to 12.5 percent of the nonparticipants. Program Funding, Costs, The program is funded by the state of Illinois and The Ounce of Preven- tion Fund. Total funding in fiscal year 1988 was $315,300, with 71 per- and Benefits cent 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 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. Page 81 GAO/HRD9083 Home Visiting Appendix I Description of the Eight Home-Visiting Programs GAO Visited Maternal and Child Health Advocate Program Table 1.5: 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 oriainallv hired: 9 as proaram 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 appropriate use of prenatal and child health care to improve pregnancy outcomes and infant health. The project targeted pregnant women enrolled in spe- cific prenatal clinics and women with high-risk newborns in the Chil- dren’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, Y 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. Page 82 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight Home4%iting ProgramsGAO Visited Program Services and The advocates provided case management, referral, and counseling ser- Activities vices 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) pro- vided 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 con- ducting 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 sug- gested minimum number of visits and the appropriate services to be given at various stages. For example, during the third trimester of preg- nancy, 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) 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 cul- turally sensitive and had good interpersonal skills. Two of their supervi- sors 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 paraprofes- sional. 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 Page 83 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight HomeVisiting F+rogranwGAO Visited visits, and (3) a comparison group who received no visits. Evaluation results were to be available in 1990. Program Funding, Costs, The program received funding from the Michigan Department of Health, and Benefits 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 $609,000 used primarily for evaluation during the first 2 years. VISTA provided funds that were used to pay sub- sistence 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 empha- sizing 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 chil- dren from four communities in Detroit’s Eastside. The project is funded by HHS and the Michigan Department of Public Health. Page 84 GAO/H&D-90-83Home Visiting Appendix I DeecrlpUon of the JSightHome4%Wing Pro@xuneGAO Visited Changing the Configuration of Early Prenatal Care Table 1.6: Program Profile: Changing the ppy;;guration of Early Prenatal Care 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 aestation 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 fundina: $459,545 Evaluation results: Not completed Background The Changing the Configuration of Early Prenatal Care project in Provi- dence 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 out- comes for high-risk, inner-city women through mid-pregnancy prenatal care home intervention. To accomplish this goal, the project sought to (1) increase the 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. Page 85 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight Home-Visiting Pro@uns GAO Visited 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 super- visor to provide EPIC services. Program Services and EPIC provided services in five broad areas: (1) medical prenatal services, Activities (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 preg- nancy and referrals to other providers. Based on observations, ques- tions, 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. The EPIC nurses had bachelor’s degrees in nursing, had several years of home-visiting experience, and were selected because they were compas- sionate, 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 pro- gram 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 Page 86 GAO/HRDM-t33 Home Visiting Appendix I DeecrIption of the Eight Home-Visiting Frognuns GAO Visited 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 eval- uation 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 WIG 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, EPIC was funded entirely by a 3year $459,545 federal SPRANSgrant. and Benefits 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 spec- ulated that if evaluation results were positive, the 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 ser- vices, if necessary. If the program were continued, it would be adminis- tered 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. Page 87 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight Home-Visiting Programs GAO Visited Great Britain’s Health Visitor Program Table 1.7: Program Profile: Qreat 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 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 pro- gram 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, Page 88 GAO/HRDBO-83HomeVisiting Appendix I Description of the Eight Home-Visiting Programs GAO Visited there are 14 regional health authorities and 191 district health authori- ties. 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 During a health visit, the focus is on health promotion and education, Activities 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 unantici- pated 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-l/2 to 3 years of age. In most cases, the health visitor independently provides the advice, gui- dance, 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. Page 89 GAO/HRD-90-83Home Visiting Appendix I Description of the Eight HomeVisiting ProgmmaGAO Visited Senior nursing officers, who are experienced health visitors, supervise the health visitors. They usually supervise about 26 visitors, but this varies by district. However, the health visitors receive little direct over- sight 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, In Great Britain, total health service expenditures increased by 229 per- and Benefits cent from $14 billion in 1978 to $46 billion in 1989, not considering inflation or currency fluctuations.1 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 out- comes of their services. To this end, program officials are beginning to develop management information systems to monitor the amount and type of health visitor services delivered and to measure their success in meeting the program’s objectives. ‘The annual average exchange rate for the pound sterling for 1988 was $1.780806=1 pound. Page 90 GAO/HRD-90-98Home Visiting Appendix I Deecription of the Eight Home-Visiting Progmns GAO Visited Denmark’s Infant Health Visitor Program Table 1.8: Program Profile: Denmark’s Infant Health Vlsltor Program Geographical area served: 273 of 277 municipalities Goals/objectives: Reduce infant mortality by promoting the health and well-beina of children Service delivery method: Home-visiting and parenting classes Target population: Children through age 6 Number and timina 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 averaqe, 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 com- pulsory, but the government offered to subsidize 60 percent of the health-visiting costs for municipalities that chose to participate. Addi- tional 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 1986, 273 of the 277 Page 91 GAO/HRD-SO-83 Home Visiting Appendix I Description of the Eight Home-Visiting Pro@vunsGAO Visited 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 func- tion independently, planning and scheduling their own work. Most municipalities are small and do not employ a health visitor supervisor. Program Services and The health visitors provide many services designed to influence parental Activities 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. The health visitor has flexibility in conducting the home visits. A stan- dardized 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. Page 92 GAO/HRD-90433Home Visiting Appendix I hription of the Eight HomeVieiting ProgramsGAO Vi&cd 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 193Os, health visiting has not been evalu- ated 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, In 1985, Denmark spent $4.9 billion,2 or 5.5 percent of its gross national product, on public health services, including health visiting. Program and Benefits 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 impor- tance 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 municipalities to hire professionals other than nurses, such as social workers, to provide health-visiting services. ‘The annual average exchange rate for the Danish kroner for 1988 was $1.00=6.72809 kroner. Page 93 GAO/HRD-90-83Home Visiting Appendix II I What Happenson a Home Visit? GAO staff accompanied home visitors at every site we visited. The fol- lowing descriptions illustrate the variety of situations encountered by home visitors. Purpose of visit: To support and educate a teenager close to delivery. Aiken County, Rural South Carolina Provider: Paraprofessional, Resource Mothers Program. The client was 13 years old, 8-l/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 run- ning 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 contin- gency 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. Purpose of visit: To work on fine motor, language, and cognitive skills Austin, Texas 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 mother, 32 years old with a seventh grade educa- tion, was included in these structured activities. The mother spoke to the child in a mixture of Spanish and English. The home visitor Page 94 GAO/HRD-90-83Home Visiting Appendix II What Happens on a Home Visit? 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. Purpose of visit: To educate and support a teen mother. Anna, a Small Town in Rural Illinois 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 her- self. 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 con- trol 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. Purpose of visit: To discuss the mother’s needs, the child’s development, Altgeld Gardens, a and the home situation since the last visit. Housing Development in Urban Chicago 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 Y 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 boyfriend’s, then to a grandfather’s in Page 95 GAO/HRDMW Home Visiting , Appendix II What Happens on 8 Home Vi&? 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 WP. 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 situa- tion still produced problems, finding employment had helped. The home visitor informed the mother about sources of financial support for col- lege. In addition, the home visitor gave the mother suggestions for devel- opmental activities for the child. The home visitor would see this client again that week at the program’s group meeting. Purpose of visit: To check on the status of breast-feeding, weigh the Holbaek, a Small Town child, and respond to the mother’s questions. in Denmark 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 spa- cious 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 main- tained through the parents’ group. Purpose of visit: To physically check children and assess living condi- Mid G1*organ Hea1th tions of higher risk families, District, Rural Wales Provider: Professional nurse. The two families visited were living in trailers in a gypsy caravan park. Y These nomadic families travel throughout Great Britain, parking on vacant or public lands. This caravan park was very dirty and lacked Page 96 GAO/HRD-90-33Home Visiting Appendix II What Happens on 8 Home Visit? running water. A water pump was available down the road. Both fami- lies had troubled histories of alcohol, violence, or child abuse. One family’s 6-year-old and 2-l/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 acci- dent, 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 fami- lies resist authority of any kind. These families needed to be visited more frequently because of their many problems. Purpose of visit: To check on the health progress of a toddler. Oxfordshire Health District, Suburban Provider: Professional nurse. London The home visitor made a routine visit to an l&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 vis- itor 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. Page 97 GAO/HRD-96-83 Home Vi&ing I Appendix III CommentsFrom the Department of Education UNITED STATES DEPARTMENT OF EDUCATION OFFICE OF SPECIAL EDLICATION AND REHAQtLlTATXVE SERVICRS THE ASSISTN~T SECRETARY Ms. Linda G. Morra Director, Intergovernmental and Management Issues United States General Accounting Office Washington, D.C. 20548 pear Ms. Morra: Thank you for the opportunity to comnent on the draft report to the Congress on the use of home visiting as an early intervention strategy for at-rink families. Home visiting is supported by the Department as a useful mechanisa for providing services to infants, toddlers and young children with disabilities. We believe, howwet, that States and local providers should decide which mechanisma and setting8 are appropriate to meet the individual needs of these children. In general, the Department believes that the report is well written and well organized, and is generally responsive to the questions that guided the study. Soms of the conclusions that are drawn (home visitation prcgrams can be effective intervention strategies for at-risk families: home visitation programs can be cost effective) are reasonably supported by the studies cited in the report. Hover, other conclusions (and corresponding reconmendatione) are not well supprted in the report. The following is a reiteration of the recomnendations made to the Secretary in the draft report, and the Departmantle response to each recommendation : 0 Wiquire pederally mpported prcgrama that um how visiting to incorporate certain critical program design components for developing and managing home visiting services, including : (a) clear objectives, which are used to manage program progress and to evaluate program outcomes: (b) structured mNiC5S by trained and aupe~imd hwn visitors whose skills match the services they deliver: (c) close linkages to other service organizations to facilitate case management: and (d) ccmnitments for further funding beyond any Federal demrustration period to sustain benefits beyond short- Y term initiatives. Page 98 GAO/HRD-99-83 Home Visiting Appendix III CommentsFrom the Department of Education Page 2 - Ma. Linda G. Morra l)epartment of Education Response Although many of the design components recommended for inclusion in home visiting programs may bs related to program successI there is insufficient evidence presented in the report or other- wise available that demonstrates that those particular components are key to success or, if absent, lead to failure. As noted in the report, most of the information about these key design components were derived from evaluators’ statements or euppositions about reasons for not accomplishing objectives, rather than from systematic research designed to identify which variables are causally related to specific outcomes. We believe that consideration of the design components named in the report represent working hypotheses that should now be verified through research rather than requiring that they be included in every program funded. It is also important to note that most of the recommended design components are already included in the selection criteria for projects funded under the Handicapped Children’s Early Sducation Program (clear objectives and expected outcomes; a well-defined target population: services specifically designed for target Population: personnel skills suited to achieve program objectives: systematic evaluation: and (under our Outreach program) assurance of continued services as a condition of receipt of funds. RECOMMSNDATIONTHE SSCRES!ARyOF aWCATION 0 Rake existing materials on home visiting more widely available through established clearinghouses, conferences and commmications with States and grantees. Department of Education Response We agree that existing materials on home visiting, as well as materials related to other strategies and settings for services, should be made more widely available through existing mechanisms. RECQ4MENDATION'K)TSE SECRETAWOF EDUCATION 0 Provide technical or other assistance to more systematically evaluate the coats, benefits, and potential cost savings associated with homs-visiting services. Department of Education Response The Department agrees with this recoranendation, although we believe that technical assistance ia premature until the evaluation phase has been completed. The Department is supporting several research and other projects to evaluate home- visiting services such as a project at Utah State University that is conducting several studies to determine the costs and effects Y of different kinds and intensities of home-visiting programs for children with various disabilities. Page 99 GAO/HRD90-83 Home Visiting AppendlxlIl CommentaFromtheDepartment of JMucaUon Page 3 - Me. Linda G. Morre RKXWRlDATICBllU THE SECRFITARYOPEWCATION 0 Give viority to Federal deuonetration projects designed to (1) oDet the multiple need8 of target populations, (21 incorporate hams visiting permanently into local maternal and child health end welfare service eyeWr and (3) replicate medele that have demonstrated their efficacy. Department of Education Response We agree with (1) and (3) of this recomnendation: however, home- visiting programs should not be given priority over other approaches or settings for services since there is insufficient evidence of their superiority over other approaches. RECOMMPNDATIONIOlWESSCREl'ARYOF EEUCATION 0 Charge the Federal Interagency cbxdinating Council with the Pederal leadership role in coordinating end assisting home- visiting initiativea. Department of education Response We agree with this recommendation. However, since there is insufficient evidence that home-visiting programs are superior to other approaches or settings for eervicee, we do not think the FICC should promote home-visiting programs as superior approaches or promote them to the exclueion of other programs. Thank you for the opportunity to comnent on this report. I and members of my staff are prepared to respond, if you or your representatives have any questions. I have provided technical comnente related to the draft report that are indicated on the appropriate pages included as Enclosure A. Robert R. Davila hcloeure Page100 GAO/HRD-90-33 Home Visiting Cknments From the Department of Health ayld Human Services DEPARTMENTOFHEALTH&HUMANSERVlCES OfliceofInlDIClor General Washington. DC. 20201 Ms. Linda G. Morra Director, Intergovernmental and Management Issues United States General Accounting Office Washington, D.C. 20540 Dear Ms. Morra: Enclosed are the Department's comments on your draft report, Wome Visiting: A Promising Early Intervention Strategy For At-Rick Families." The comments represent the tentative position of the Department and are subject to reevaluation when the final version of this report is received. The Department appreciates the opportunity to comment on this draft report before its publication. Sincerely yours, Q'(mJ-J Richard P. Kusserow Inspector General Enclosure Page101 Appendix IV CommentraF’romthe Department of Health and Human Services COMMENTSOF THE DEPARTMENTOF HEALTH AND RUMANSERVICES ON THE GENERALACCOUNTINGOFFICE (GAO) DRAFT REPORT, "HOME VISITING8 A PROMISING SARLY INTERVENTION STRATEGY FOR AT-RISK FAMILIES" General Comments This report is an extensive compilation and discussion of experience and observations regarding home visiting in the United States. It is informative and covers a broad range of topics related to the types of programs available and presents detailed information about a small set of these programs in the United States. It provides a significant concept of home visiting. While this report shows that home visiting can be an effective intervention for at-risk families in certain circumstances, several contextual features of home visiting that could affect its success in the United States are not dealt with by GAO to a sufficient extent. Although the experiences of Denmark and the United Kingdom are cited, the report does not make clear that these programs operate in a very different context, that of universal coat-free access to health care and a lengthy tradition of social welfare that is much less claee-based than welfare in the United States. Also, the population of Denmark, and until recently, the United Kingdom, hae been much less ethnically diverse than the United Statea' population. Their infant outcomes are much better (as measured by low birthweight and infant mortality). The report does not discuss existing programs in the United States which use home visiting and have the ongoing funding and institutional base that the report states are necessary criteria for success. One example would be public health nursing. Public health nursing has had many of the functions that the GAO ascribes to home visiting programs but has had to struggle to maintain its funding base. Guaranteeing firm funding to public health nursing and supporting expansion of those services might be a cost-effective alternative to expanding the patchwork of community-based service organizations. This report should have included a thorough discussion of the pros and cons of building home visiting programs around public health nursing. An alternative would be using the infraetructure of other existing welfare programs. The report does not distinguish home visiting from case management although it shares certain features of case management, e.g., linking clients to servicea. These two forms of intervention ehould be defined and distinguished from each other. For instance, case-management services for at-risk families with children under 2 should be expanded to include systematic home visiting. Page 102 GAO/HRD-90-33Home Visiting Appendix IV Cbmmenta From the Department of Health and Human Servlcee 2 The report uses an implicit model of service delivery that can be reasonably characterized as the American "patchwork" of care eystem. The report does not fully address how to integrate one new service into the existing and somewhat fragmented health care system in the United States. However, the report does raise the possibility that weak effects of these programs may in part be due to fragmentation. Arguably, the weak effects could be due to historical effects outside of program control. If a home visiting program is put into place just as welfare benefits run out or as the last public hospital in town closes its doors, the chances for ehowing positive program outcomes will be decreased. The report states that there has not been extensive evaluation of home-visiting programs. Apparently, while a few studies ;~~b~~ methodologically acceptable, many evaluations have . Thus, it will be very important to evaluate how well the recmended "design components" actually serve the diverae rtaff and client populations that will u8e them in various nettings. Therefore, it should be a requirement that programs have an evaluation component , not merely that technical aseietance be provided to do evaluations. At some point in the future, a number of well-done evaluations could be reviewed and more firmly-based conclusions regarding effectiveness and cost could be reached. The report appears to propose home visiting not am a specific service, but as a mechanism for providing services to high-risk populations. These home-based services include coaching, counseling, teaching , some direct health services, and referral to appropriate community resourcea for additional services. The questions of who vieita, what services, and frequency depend upon clear objectives and specific services matched to the target population'e needs and to the home visitors' skills and abilities. Home visiting should not stand in ieolation and should not be the sole subetitute for gape in crucial health services. Much of the success of home visiting ::$~;~sconnecting families to a wide-array of community . The report's findinga have important implications for rural areas of the United States where the lack of transportation services make home visiting a key element in ensuring access to health services for disadvantaged families with young children. We alao agree that home visiting is an effective component of an early intervention strategy (as it consiste of outreach, informing, care coordination, and case management strategies). Page103 GAO/Iil?B~Home Visiting AppendixIV CommenteF'romtheDepartmentofHeaMh andHumanServices 3 GAO Recommendation The Secretaries of HHS and Education should require federally supported programs that use home visiting to incorporate certain critical program design components for developing and managing home-visiting services. Specifically, the Secretary of HHS should incorporate these program design components when impl'ementing the home-visiting demonstration projects from the MCH Block Grant. HNS Comment We concur. The MCH staff of the Health Resources and Services Administration have the responsibility of implementing the recently authorized Omnibus Budget Reconciliation Act of 1989 home visiting demonstration projects. The new authority come8 into effect only when the MCH Block Grant reaches $600 million. After further evaluation of the MCH program design components for home-vieiting, we will coneider their applicability to other programs of the Department. GAO Recommendation The Secretaries of HHS and Education should make existing materials on home visiting more widely available through established mechanisms, such aa agency clearinghouses. IiHS Comment We concur. Home-visiting activities will be integrated with the existing clearinghouse activities of the MCH program of the Health Resources and Services Administration (HRSA). GAO Recommendation The Secretaries of HHS and Education should provide technical or other assistance to more systematically evaluate the costs, benefits, and potential cost savings associated with home-visiting services. Xiii6 Comment We concur. Technical assistance and cost evaluation studies are being done currently under Special Projects of Regional and National Significance (SPRANS) grants funded by the MCH program. Page104 * . Appendix IV CommentaFromtheDepartmentofHealth andHuma.nServices 4 GAO Recommendation The Secretaries of HI-IS and Education should give priority to federal 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. IiliS Comment We concur to the extent that funding priority for demonstration projects is within existing programs such as the grants funded in HRSA for health care services in the home. Our reservations are based on the questions that remain regarding the efficacy and especially the effectiveness of home visiting intervention programs. Such evaluations must be carefully controlled and use valid scientific measurements. It ie critically important that careful evaluation of home visiting intervention strategies for specific outcomes such as infectioue disease control, child development or pregnancy not be compromised. Other factors to be analyzed ehould include those having to do with improved cognitive, intellectual and psychological development of children. Therefore, research and evaluation componenta should be built into any program euch as the one proposed in the GAO report. GAO Recommendation The Secretaries of HHS and Education should charge the Federal Interagency Coordinating Council (FICC) with the federal leadership role in coordinating and assisting home-visiting initiatives. HHS Comment We do not concur fully because we believe that the FICC was created in principle to bring multiple agencies together to implement the Education for Handicapped Act program. In this program, home visiting, or prenatal and postnatal care, are important but tangential elements. The GAO proposed charge for FICC would add an additional agenda and different focus for thie staff group. While such a charge may be of benefit in providing services to preschoolers and their families, the myriad of existing interagency agreements and cooperative agreements may be limiting factors for the FICC. Page 105 GAO/HRD3O+33Home Visiting Appendix IV CommentsFrom the Department of Health and Human Services 5 Matter for Consideration bv the Congrese 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, especially for high-risk families, the Congress should consider amending title XIX of the Social Security Act to explicitly establish a6 an optional Medicaid service, when prescribed by a physician, (1) prenatal and postnatal home-visiting services for high-risk women, and (2) home-visiting services for high- risk infanta at least up to age one. IsiS Comment The GAO proposal to amend the Medicaid statute to establish explicitly optional prenatal and postnatal home-visiting services for pregnant women and infants is unnecessary. States essentially have that option now. Home visiting has been a classic public health nursing function since the turn of the century. Under Medicaid, home visiting can be provided under a variety of categories of medical services, including home health service under section 1905 (a)(7), case management services under section 1905 (a)(19) and nurse practitioner services under section 1905 (a)(21). It could also be provided under the general category or any other medical or remedial care under section 1905 (a)(22). AS part of State plan administration, home visiting is provided to conduct outreach, informing or administrative case management. In short, there is no statutory barrier to provision of pregnancy-related home visiting services under the current Medicaid law. A greater problem is the fact that, typically, high-risk populations like substance abueers and pregnant teens do not seek care. Without effective outreach, availability of home visiting services will not have a significant impact on Medicaid-eligible, high-risk populations not being served by the program. Y Page 100 GAO/HRD-MS Home Visiting Appendix V Major Contributors to This Report Kathryn G. Allen, Project Director, (202) 276-8894 Human Resources David D. Bellis, Project Manager Division, Sheila Avruch, Evaluator Washin&on, DC. Hannah F. Fein, Writing Specialist Shellee S. Soliday, Deputy Project Manager Atlanta Regional Cheri Y. White, Evaluator Office Adrienne F. Friedman, Site Senior Chicago Regional Judith A. Michaels, Evaluator Office Charles F. Smith, Site Senior European Office Ann Calvaresi-Barr, Evaluator Y :118884) Page 107 GAO/HRD99-33 Home Visiting _. --.-. __--_ - r 1Ccq11t~st s for cwpic*s of’ (;A0 wporl s sl~t~r~ltl lw wn t to: i
Home Visiting: A Promising Early Intervention Strategy for At-Risk Families
Published by the Government Accountability Office on 1990-07-11.
Below is a raw (and likely hideous) rendition of the original report. (PDF)