oversight

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)

                                                                                                                                    .I U.
                      --_---   _- ..__..-_
                                       ..”
                                        ,.__    Il~~ittvJ
                                           _...““_
                                               .__.__.._...  St~tw
                                                     l-_.“l”_l_---    (ktlr~ral       +_c-counting       Offiw
                                                                                                          ~----.-~---~-.
                                               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