Home Visiting: A Promising Early Intervention Service Delivery Strategy

Published by the Government Accountability Office on 1990-10-02.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

4                            United States General Accounting Office        I423-

    For Release               HOME VISITING
    on Delivery
    Expected      at
    IO:00    a.m.    EST      A Promising      Early     Intervention
                              Service    Delivery       Strategy
    October     2, 1990

                              Statement      of
                              Linda    G. Morra,       Director
                              Intergovernmental           and Management        Issues
                              Human Resources          Division

                              Before   the
                              Subcommittee       on Government     Activities
                              and Transportation,        Committee      on
                              Government     Operations
                              House of Representatives

    GAU/'l'-HKLI - Yl - 02
                                                                                         GAO Form 160 (12/87)

                               SERVICE DELIVERY STRATEGY
                                      Summary Statem ent       of
                                          Linda G. M orra
                              Director,     Intergovernm ental         and
                                        M anagem ent Issues
    The Subcom m ittee         on Governm ent Activities             and Transportation       of
    the House Com m ittee on Governm ent Operations                       is considering
    legislation          to sell governm ent-owned           land in the District         of
    Colum bia to Colum bia Hospital               for Women. Colum bia Hospital              has
    proposed       establishing        a National      Women's Health Resource Center,
    that will        provide     clinical,     research,       education,      and advocacy
    programs of local            and national       significance.           To aid in the
    deliberations,           GAO was asked to testify             on hom e visiting      as a way
    to deliver        preventive       health   and social        services     to wom en and
    their     fam ilies.
    From an analysis          of the literature           and case studies,         GAO has
    concluded      that hom e visiting           is a prom ising      service     delivery
    strategy     to improve birth            outcom es,    prevent    child   m altreatm ent,
    and improve child          health      and developm ent.         Hom e visiting       can be
    particularly       useful     for wom en at risk of poor outcom es,                 such as
    teenage m others,         substance-abusing           wom en, and wom en living          in
    rural    areas where transportation               to services        can be a barrier.       It
    can provide       services      directly       in the hom e or link wom en to other
    needed services         provided       elsewhere.        Hom e visiting      com bines
    coaching,      counseling,        teaching,      referrals,      and som etim es hands-on
    Not all programs that have used hom e visiting             have been successful
    at achieving     their    objectives.     GAO identified    characteristics     that
    strengthen    program design in a recent         report  (Hom e Visitins:   A
    Prom isins   Earlv Intervention       Strateav   for At-Risk    Families
    [GAO/HRD-90-831,       July 1990).
    M ore research      is needed to identify        the m ost cost-effective         ways
    to improve birth        outcom es and m aternal      and child     health     and well-
    being.      At least    five issues need further         research:        (1) For what
    populations      and outcom es is hom e visiting         m ost cost-effective?
     (2) Should hom e visiting        be universal      or targeted?        (3) What type
    of hom e visitor--professional          or paraprofessional--is            m ost
    effective?       (4)   What service     configurations       are m ost cost
    beneficial?        (5) What curriculum      or structured       plan of services        is
    m ost effective?
Madam Chairwoman                   and Members of the                        Committee:

We are       pleased             to be here          today        to    assist                 in your           deliberations               on
the      issue      of    conveying              certain         federal                real         property           in the
District          of     Columbia           to     Columbia           Hospital                 for         Women.        The intent
of this          proposal          is   to       establish            a National                     Women's Health
Resource          Center         that       will     provide           clinical,                     research,           education,
and advocacy              programs           of national,               as well                 as local,               significance.
Within       this        context,           you asked            the    General                 Accounting               Office        to
discuss          home visiting               as a strategy                   for         delivering               preventive
health       and social             services             to women and their                                families.

My remarks             today       are based             on our July                    1990 report,                   Home Visiting:
A Promisins              Earlv      Intervention                 Strateav                for         At-Risk           Families
(GAO/HRD-90-83).                    To assess              the    scope,            nature,                 and effectiveness                    of
home visiting,                 we reviewed               the     literature                    and interviewed                    experts
here       and abroad             in the         areas      of medical,                   social,              and educational
interventions.                   Through           case studies               of eight                     home visiting
programs          in Great          .Britain,            Denmark,            and five                 U.S.       states,          we
identified             design       characteristics                    important                     for     developing            and
operating           effective           programs.

Home visiting               is     a promising              strategy               for         delivering               early
intervention              services,              especially            for         vulnerable                  populations.                 In
addition          to working            with        families           in their                 homes,          home visitors                can
help     them       access         other,          center-based               services.                      Such combined


services            can improve             the     health        and well-being                    of pregnant              and
parenting             women and their                 children.            Home visiting                     is particularly
valuable            for      women at risk             of poor          outcomes,                 such as low-
birthweight                babies.          But more research                       is    needed         on the       most cost-
effective             ways to provide                 early       intervention                    services       and structure
home visiting                  services.


Home visiting                 involves            coaching,          counseling,               teaching,            referrals
to     other        service          providers,         and sometimes                     hands-on           health         care.
It      focuses           on establishing              a relationship                     of trust           and support
that         motivates          a woman and her                 family         to        seek and remain                in care.
It      is    not    a program,             but     a strategy           for         getting          early      and
preventive                health,      social         support,          or educational                    services           to

Visits         to    the      home can reach              the        llhard-to-reachll                   woman, such as
substance-abusing                     women, pregnant                 teens,             or families           living           in
rural         locations             where    public       transportation                     is     limited         and
services            few.        Home visits            can help          such women overcome                          the
barriers            they      often      face       in getting           services              they       need and are
entitled            to.       Helping        families         access           preventive                services         such as
center-based                prenatal         care      can be less              costly            than     paying         for        the
consequences                 of poor        birth      outcomes.               Such outcomes                  can include              a
low-birthweight                baby who needs                      extended            neonatal       intensive              care,
and possibly            additional                medical           care        and special           education
services          due to       long-term              disabilities.

What happens            on a home visit?                         The activities                   can vary          greatly,
depending          on the        needs        of the          family            and the         program         objectives.
As part       of      our     study,       we accompanied                       home visitors               on their              rounds
in each of the                eight      programs             we visited.                  In South          Carolina,                 we
saw a home visitor                    work with              an 8-l/2-month                   pregnant          13-year-old,                      a
victim      of     abuse       who had run away,                         time      and again,            from       foster
homes.        For this           young        girl,          the        home visitor             provided           practical
guidance,          such as what               to do if              alone        when going           into         labor,          and
offered       emotional              support.             In Chicago,                  we observed           a home visitor
advise      a teen          mother       on the           best          developmental              activities               for        her
baby and on how to                    apply        for       college            aid.      In Austin,             Texas,            a home
visitor       tutored          a child          with         delayed            speech        development            and her
mother      in activities                designed             to        improve         her     speech       and
development.                The visitor               also       discussed              scheduling           the     child             for        a
center-based            speech         assessment                at the          University           of Texas.                   In
Great      Britain,           a home visitor                  checked            two gypsy          children           for
scabies          (parasitic           mites        that       burrow         under        the      skin),          following                 up
on a previous               clinic       visit.

So far,              no single                    model      of home visiting                  has been shown to be most
effective.                      Goals,             services,           providers,             and clients            served      tend     to
vary       (see table                       1).

Table           1:     Examoles                    of Proarams               YJsina Home Visitinq                   To Serve        At-
Risk       Families
           Goals           --                                 Improved              parenting    skills
                                                              Enhanced              child   development
                                                              Improved              birth   outcomes
           Services                   --                      Information   delivery
                                                              Referrals   to other service                           providers
                                                              Emotional   support
                                                              Health care
           Providers                   --                     Nurses
                                                              Social workers
           Clients               --                           Pregnant and/or parenting     teens
                                                              High-risk   newborns
                                                              Developmentally    delayed children
                                                              Families   at risk of child   maltreatment

Some services                     are primarily                   home-based,                 while     others        operate        as
part       of        a home- and center-based                                     program.        One home-based               program
in Elmira,                 N.Y.,             used nurses               for        prenatal       and postnatal               home
visiting              to    improve                 birth      outcomes              and infant         health.          The
Resource              Mothers                for     Pregnant           Teens program                 in South        Carolina        used
paraprofessional                             home visitors                   to    reduce      infant        mortality         and
morbidity              and improve                     the     teens'             parenting       skills.            Home visiting
has been a part                            of numerous            successful                 center-based            early
intervention                    programs               to     improve             child      development            and later        school
success.               Such programs                         include          the     High/Scope            Perry     Preschool

Program,          the     Infant          Health         and Development                  Program,           and the
Brookline,             Massachusetts,                 Early         Education           Project.             Home visitors
have         reached      many types             of clients:                  premature            or low-birthweight
infants,          low-income              pregnant           women, teen               mothers,        and
developmentally                   delayed        preschoolers.

Many states              and localities                  use home visiting                    to    improve        women and
children's             health       and well-being.                      Researchers               have      identified
over      4,500        programs           in the         United        States          that       use home visiting.
Twenty-four              states       now reimburse                   pre-     or postnatal               providers         of
home visiting                  services         through           Medicaid.             The Congress             has shown
interest          in home visiting,                      having        recently           passed       several        pieces
of     legislation              concerning            it.         The Omnibus             Budget       Reconciliation
Act     of     1989      (P.L.      101-239)             authorized            new home visiting
demonstration              grants,          although              no fiscal            year       1990 funds        were
appropriated.                   In addition,                the     Child      Abuse Prevention,                   Adoption,
and Family             Services           Act    of      1988        (P.L.     100-294)            encouraged         the    use
of home visiting                   to prevent               child      maltreatment.

Evaluation             evidence           has demonstrated                   that       home visiting              can be
beneficial--given                   certain           conditions              that      I will       discuss        in a
moment.           Home-visited              women have had healthier                               babies,       have been
reported          less         frequently          for       child       abuse         and neglect,            and have
sought         more appropriate                  pediatric             care      for      their      children.            Home-
visited         children           have had improved                     cognitive            development,            compared
to    children           not     home visited.
Not all       programs         that          use home visiting,                   however,       succeed.             Some
have had little               impact          in achieving              their      stated      objectives.               In
our     recent      report,          we identified                characteristics              that        strengthen
the     design      and implementation                     of home visiting                  services.            Briefly,
they     include:

         1.       Developing             clear         objectives          that      are used to            focus      and
                  manage the             program;

         2.       Carefully            planning          service         delivery,           so that        the     skills
                  of the       home visitors                match        the      services       to be provided
                  and the           client       population's              needs:

         3.       Working           through           an agency         that      is capable          of    arranging
                  for,      or delivering,                 a wide        range       of   services          needed       by
                  the     client        population;               and

         4.       Developing             strategies           to       secure      funding       over       time,      to
                  allow       for      service          continuity.

One program          that      puts          many of these              principles           to work        is the
Roseland/Altgeld               Adolescent               Parent         Project       in Chicago.             Using       a
home- and center-based                        approach,           it    serves       low-income            pregnant
teens      and teenage              mothers       who lack             a family       or other          "support
system."          In selecting                their      target         population,           this     program's
managers         were     careful            and realistic.                They designed              home visiting
services        with      a specific            group     of teen            mothers          to     reach--those                who
needed      and could         benefit           from     extra       support.                But     they          also

recognize        their       limitations.                Program            staff      refer         pregnant              and
parenting        teens       with      severe       mental          and emotional                   disorders              to
other,      more intensive               programs         where        they          might         be better              served.
Additionally,             program       managers          determine                 whether         they       are meeting
program      objectives              by routinely              monitoring             program             activities,
such as whether              project         infants           receive         a minimum number                       of well-
baby pediatric             visits.


Consensus        on the       effectiveness               of home visiting                         as an early
intervention             strategy        is growing.                The Public               Health          Service
Expert      Panel       on the        Content       of    Prenatal             Care recently                  highlighted
home visiting             as a recommended                part       of prenatal                   care      for      women at
risk.l         In addition,            the      Office         of Technology                 Assessment
recommended            encouraging           the    development                of nurse             home visitor
programs        for     women at         risk      of poor          birth           outcomes         or of child
maltreatment.2               While       support         for       home visiting                   is growing,              we

lExpert   Panel on the Content of Prenatal      Care, Carinc for
ou r Future. . The Content of Prenatal    Care (Washington,    D.C., U.S.
Public   Health Service,  Department   of Health and Human Services,
20ffice   of Technology     Assessment,   Healthy Children:
Investina    in the Future,     OTA-H-345 (Washington,     D.C.,                                               U.S.
Government Printing     Office,    1988).
believe        that   more research                  is   needed           to determine            the           most cost-
effective         ways to       reach         and help            women and children                        at     risk    of
adverse        outcomes.

We see at         least      five         issues      where         more research            on home visiting
is   needed.

          1.      For what          populations              and desired             outcomes               is home
                 visiting           the     most cost-effective                      strategy?                   Can center-
                 based       services          achieve            the      same result            at        less       cost?

          2.     Would home visiting                      be more effective                  if        it        was
                 universally               available          to     all      pregnant       women or parents,
                  or should          it     be targeted              to particular                families
                 according           to     certain          risk        criteria?

          3.     What type           of home visitor--professionals                                    or
                 paraprofessionals                   --are        best      suited      to provide                  specific
                  services          for     specific          populations?

       4.        What are           the     costs,        benefits,            and relative                  cost-
                 effectiveness               of using             different          types        of providers                  and
                 providing           home visiting                  services         that    vary            in     intensity
                 and duration?


              5.           What curriculum                    or structured                plan         for      services               is most
                           effective              with      particular            populations?
    The British                  model        of home visiting                   is one that                  could          be evaluated
    experimentally                      in the        United       States.             In Great               Britain,            specially
    trained           nurse         home visitors                function          as part              of the              medical       team,
    which          also         includes          physicians           and midwives.                     Their              services        are
    part      of the             National            Health      Service,          which          provides                  comprehensive
    medical          care         for      all       residents         of Great            Britain.                   All      families          with
    young          children             are      eligible        for     their         services,               which          are provided
    without          charge.               The health            visitor          follows          each child                   from birth
    through          age 5, with                  a combination               of home and center                             visits.         The
    health          visitor             meets        the    pregnant          woman before                    birth          and begins
    home visiting                  within            14 days       of delivery.                   Health          visitors               educate
    families              about         breast-feeding,                infant          immunizations,                        accident
    prevention,                  and appropriate                 pediatric             health           care.               They monitor
    the     child's             development,                so that          potential            problems,                  such as poor
    hearing,              can be identified                    and addressed                as soon as possible.

    Key elements                  of the          British        model        could        be tested                  on an
    experimental                  basis          in the       United         States.          In addition                     to the
    research              issues         highlighted             above,         clinical           trials              could           address

              --          the     costs          and benefits            of combining                   supportive                home
                       visiting               with       medical       care,       where          the     home visitor
                          functions              as part       of the         medical         team,            and

           --     whether            a nonnurse           could      fill          this     role.


Many states                  and localities             use home visiting,                     and there         are
indications                  that    their      numbers       will          grow.         Home visiting              holds
promise          as a strategy                 to     reach   some high-risk                   women and their
children.               It      can link        them to the            services             they      need and promote
positive          health            and social          behaviors.

But some of this                     effort         may be wasted             if      programs         are     not    well
designed          and managed.                  The framework                for      designing         and managing
programs          outlined            in our home visiting                         report      provides         some
guidance.           Answering                 other     research            questions          will     help     to    further
target          where         and with         whom home visiting                     can be most effective.

Madam Chairwoman,                     this      concludes         my statement.                     I would      be pleased
to   respond        to          any questions            you or other                 members of the             Committee
may have          regarding             our work.