EVIDENCE-BASED HOME VISITING PROGRAMS
WHAT ARE EVIDENCE-BASED HOME VISITING PROGRAMS AND WHY ARE THEY IMPORTANT?
Home visiting programs, which provide support and education to parents in the home through a trained professional (e.g., nurse or social worker) or paraprofessional, have a growing evidence base and have expanded rapidly over the last decade as a state-based investment to support parents and children.1
Supporting Families in the Early Years Produces Long-Term Benefits
Parents play a critical role in shaping children’s early development.2 Improving parents’ knowledge, social support, and coping and problem-solving skills, as well as connecting families to community and health resources during the prenatal and early childhood periods, promotes positive long-term child development.3 Teaching parents the skills for warm and responsive caregiving can buffer the long-term negative effects of childhood stress and adversity.4
Traditional and Virtual Home-Visiting Services Provide Multiple Ways to Keep Families Engaged
For some families, the convenience of home-based service delivery can maximize the likelihood that they will participate by eliminating or reducing barriers such as transportation costs and child care needs.5 In-home support may make it easier for the entire family to participate, and this delivery method may facilitate more personalized, individual attention, potentially increasing families’ engagement in the programs.6 Further increasing accessibility, many home visiting programs transitioned to virtual sessions during the COVID-19 pandemic. The availability of virtual sessions makes home visiting an option even to those who may have opted out of traditional home visiting services because of personal or cultural preferences.
WHAT IMPACT DO EVIDENCE-BASED HOME VISITING PROGRAMS HAVE?
Participation in evidence-based home visiting programs leads to small but positive impacts on parenting skills, but these effects exist within the context of many more null findings. Impacts are inconclusive across program models on other important child and family outcomes, including birth outcomes,7,8 child maltreatment,9,10 and child health.11,12 Given the amount of inconclusive evidence for non-parenting outcomes, our evidence review focuses solely on the impact of home visiting on parenting outcomes.
More Research Is Needed to Understand the Potential of Home Visiting Programs to Reduce Racial and Ethnic Disparities
Most of the research on parenting outcomes in home visiting programs either does not examine impacts by race and ethnicity, or no significant differences emerge in subgroup analyses. Research does suggest that matching clients and home visitors on race and/or ethnicity can have better effects on birth outcomes, but this finding does not hold for parenting outcomes.13 Future studies should examine differential impacts of evidence-based home visiting programs based on race and ethnicity.
HOW CAN STATES EFFECTIVELY IMPLEMENT HOME VISITING PROGRAMS?
In contrast to the evidence for the five state-level policies that are included in this Roadmap, the current evidence base does not identify a specific policy lever that states should adopt and fully implement to effectively provide home visiting programs to all of the families who need the services. In the absence of an evidence-based state policy lever, we present several choices that states can make to more effectively implement their home visiting programs. Additionally, we leverage available data to assess state variation in home visiting programs, and to demonstrate what progress states are making relative to one another.
State Leaders in Home Visiting:
- Serve a high share of their state’s low-income infants and toddlers relative to other states; and
- Use state dollars or Medicaid to support home visiting services.
Policy and Administrative Choices States Make Affect the Implementation of Their Home Visiting Programs
State home visiting programs vary considerably in the percentage of children under age 3 who are served, the number and type of program models the states implement that focus on parenting practices and that serve infants and toddlers, and the funding streams states access to support their programs, such as Medicaid.
States Can Choose From 7 Evidence-Based Home Visiting Program Models to Enhance Parenting Skills
The Home Visiting Evidence of Effectiveness (HomVEE) project identifies seven evidence-based home visiting program models that are designed for pregnant women or infants and toddlers and that have a significant impact on improving parenting skills: 1) Attachment & BioBehavioral Catch-up, 2) Early Head Start-Home Based Option, 3) Family Spirit, 4) Healthy Families America, 5) Maternal Early Childhood Sustained HV Program, 6) Nurse-Family Partnership, and 7) Parents as Teachers. Families in every state have access to at least two of the seven program models, and California offers all seven of these different programs.
Different types of home visiting models allow states the flexibility to choose program models which best align with the diverse needs of their communities. However, a greater variety of program models implemented is not strongly correlated with a higher percentage of children served.
States Can Use a Variety of Funding Mechanisms, Including Medicaid, to Improve Access to Home Visiting Programs
States use a variety of funding mechanisms, including both federal and state funds, to finance their home visiting programs. The primary federal mechanism is MIECHV funds, though states also use Medicaid, Title V Maternal and Child Health Services Block Grant, TANF, Child Welfare, and Head Start funds. These federal funds generally require state matching funds, and some states supplement the financing of their home visiting programs with additional funds including taxes, Children’s Trust Fund, and philanthropic funding.
States use their Medicaid dollars in a variety of ways. The targeted case management (TCM) benefit, through a State Plan Amendment, is one of the most common way states have funded a part of home visiting through Medicaid. Home visiting is not a service that is fully reimbursed by Medicaid, but components of the programs and services provided by the home visit can be covered by Medicaid. The TCM benefit offers states the flexibility to provide case management services to specified groups of women and children, geographic areas, identified home visiting models, and/or a set of approved providers. Using the TCM benefit for home visiting services also allows for reimbursement at the state’s normal federal matching rate, rather than a lower administrative matching rate. Others states use waivers (such as the 1115 or 1915(b) waivers) to pilot approaches for specific children or specific communities, or to integrate home visiting into Medicaid managed care arrangements.
Twenty-three states use Medicaid as a funding source for their home visiting programs. Ohio is in the process of implementing its State Plan Amendment to include home visiting as a part of its targeted case management benefit; it will become the twenty-fourth state to use Medicaid funding to finance components of its home visiting programs.
WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO MORE EFFECTIVELY IMPLEMENT EVIDENCE-BASED HOME VISITING PROGRAMS?
States have substantial latitude in how they implement their home visiting programs. Over the last year, several states took legislative or administrative action to enhance their home visiting services. In three states (Connecticut, Delaware, and Illinois) legislators strengthened the state’s home visiting programs by creating greater oversight and accountability, and increased funding. Connecticut now requires that all home visiting programs be evidence-based using the criteria establish by HomVEE, and legislates that the commissioner provide oversight to ensure model fidelity. A new law in Delaware now requires that the state produce an annual report on all evidence-based home visiting services in the state. Illinois expanded the use of Medicaid to fund home visiting programs as part of a larger health equity initiative.
In November 2020, New Mexico launched the Early Childhood Home Visiting Medicaid Expansion Workgroup to build on the success of the state’s Centennial Home Visiting pilot program to use Medicaid to fund home visiting services in the state.
Legislators in eight other states (California, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, Tennessee, and Texas) introduced legislative changes to their state’s home visiting programs, but these bills were not enacted this legislative session.
HOW DO EVIDENCE-BASED HOME VISITING PROGRAMS VARY ACROSS STATES?
The Reach of Home Visiting Programs Varies Across States, but Generally Is Small
The National Home Visiting Resource Center (NHVRC) collects data from each program model on which models are implemented in a state and how many children under age 3 are served by each program model. These data are published in the NHVRC’s annual Home Visiting Yearbook. Using data from NHVRC, it is possible to understand how many children under age 3 each state is serving in its home visiting programs, as a percentage of the total population that is under age 3. We focus on the number of children served in 2019, prior to the pandemic, because program models had to adapt their programs considerably to serve families in a remote environment during the COVID-19 pandemic.
We estimate the percentage served out of the eligible children under age 3, using the NHVRC service data (number of served children under age 3) as the numerator, and the Census Bureau’s 2019 American Community Survey data (number of children under age 3 in families with incomes of less than 150% of the FPL) as the denominator. The family income of less than 150% of the FPL was used as a proxy for the high-priority eligibility criteria typically used across home visiting programs (e.g., pregnant women, mothers under 21, single/never married mothers, parents with less than a high school education, and families with incomes below 100% of the FPL).
The reach of home visiting varies considerably across the US, but with the exception of a handful of states, the reach is relatively small. The percentage of families with young children served by home visiting programs in 2019 ranges from 35.1% in Iowa to 0.8% in Nevada. These data are not available for Vermont in 2019. Five states serve more than 20% of their eligible prenatal-to-3 population, but 13 states serve less than 5%.