COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS

WHAT ARE COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS AND WHY ARE THEY IMPORTANT?

Comprehensive screening and connection programs assess the social predictors of health that contribute to long-term child and family wellbeing, which may include housing, income support, food security, and health insurance coverage. Screening for indicators of health beyond behavioral and biological issues not only helps families, but encourages providers to take a more holistic approach to the many factors affecting a child’s health and wellbeing.1

Based on families’ identified needs, programs connect families to necessary services and supports to address concerns. Identifying needs through screenings alone is not enough to substantially improve child outcomes; referrals to, and initiation of, effective services are key aspects of these approaches to address identified areas of need.2

To be considered a comprehensive screening and connection program for this Roadmap, the program must (1) screen families for a range of social, health, and financial needs and connect the families to appropriate services; (2) be available and voluntary to all families in the service area, regardless of income or other eligibility criteria (can be geographically limited); (3) be initiated by outreach or contact from the program model, and not require that families request help first; and (4) be low touch in its service delivery, providing families with a small number of home visits or other short-term contact between families and the program.

Although many local and statewide programs have screening and referral components, the three rigorously studied comprehensive screening and connection programs are Developmental Understanding and Legal Collaboration for Everyone (DULCE), Family Connects, and HealthySteps.

Family Connects Meets Families in Participating Hospitals

Family Connects, a community-wide nurse home visiting program, offers approximately one to three visits to all new parents at participating hospitals. Based on the results of the intake assessment and concerns of the families, the nurse offers services tailored to the family’s specific needs and level of risk, including connections to available community resources.3

DULCE and HealthySteps Meet Families in Pediatric Care Settings

DULCE provides families a multi-sectored approach through its Interdisciplinary Team, which includes legal partners, Family Specialists, and medical providers, among others. At routine well-child visits, families are screened for any social and economic stressors; if needs are identified, the team works collaboratively with families and follows up with them to ensure service delivery. DULCE is available for families with infants up to 6 months old.4

HealthySteps also takes a team approach in its program model by adding a child developmental specialist into the pediatric care setting for children up to age 3. The program aims to improve parenting knowledge and behaviors to promote optimal growth and development during a child’s earliest years. Different tiers of short-term and ongoing supports are available to participating families, depending on their needs identified by the comprehensive screenings.5

Search the Prenatal-to-3 Policy Clearinghouse for an ongoing inventory of rigorous evidence reviews, including more information on comprehensive screening and connection programs.

WHAT IMPACT DO COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS HAVE?

The most rigorous studies show that comprehensive screening and connection programs successfully connect families to community resources. Evidence-based programs can also promote the use of higher-quality child care arrangements, although more research is needed in this area.

More Evidence is Needed on How Comprehensive Screening and Connection Programs Reduce Racial and Ethnic Disparities

The current evidence is insufficient in evaluating whether comprehensive screening and connection programs reduce racial and ethnic disparities in outcomes. Only four rigorous studies assess subgroup effects by race or ethnicity. An evaluation of Family Connects showed that the program had larger positive effects on infant emergency care use for those identified by the authors as “nonminority” families and families who were on Medicaid or uninsured, compared to privately insured families.6 Further, a follow-up study of families served by Family Connects at 24 months after program receipt found significant treatment effects only among “nonminority” families.7

HealthySteps was shown to have larger positive impacts on parental discipline among White mothers, but these findings may have been influenced by skewed attrition rates.8,9 Future research should consider under which circumstances such programs can have the largest positive impact on reducing racial and socioeconomic disparities.

For more information on what we know and what we still need to learn about comprehensive screening and connection programs, see the evidence review on comprehensive screening and connection programs.

HOW CAN STATES EFFECTIVELY IMPLEMENT COMPREHENSIVE SCREENING AND CONNECTION 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 comprehensive screening and connection programs to all of the families who need the services. In the absence of an evidence-based state policy lever to ensure the services effectively provide children and families the support they need, we present several choices that states can make to more effectively implement comprehensive screening and connection programs. Additionally, we leverage available data to assess state variation in programs and services across a range of factors to identify the leaders among states in serving families, and to demonstrate what progress states are making relative to one another.

State Leaders in Comprehensive Screening and Connection Programs:

  • Have a high percentage of families who access the programs relative to other states;
  • Enact legislation or establish evidence-based programs that can reach families across the state;
  • Have had a substantial and long-term implementation of one of the three evidence-based program models; and
  • Have implemented a universal program with a similar design to one of the three evidence-based program models.

Policy and Administrative Choices States Make Affect the Implementation of Comprehensive Screening and Connection Programs

States vary considerably in the percentage of children under age 3 who are served by comprehensive screening and connection programs, the program models they implement, and how they fund the programs. In most states, the programs are funded and implemented at the community level, not at the state level. However, increasingly, states are adopting legislation and developing statewide initiatives. For example, since 2013, Massachusetts has offered Welcome Family, which is based on the Family Connects model, to all new parents in five cities in the state (including Boston). In 2019, Oregon passed legislation to implement the Family Connects model statewide, and Connecticut and New Jersey took initiative this year to begin offering Family Connects statewide.

States Rely On a Variety of Funding Mechanisms to Support Comprehensive Screening and Connection Programs

DULCE, Family Connects, and HealthySteps are funded through federal, state, and private support, including a combination of local government resources, foundation support, and reimbursement from health care payers, including Medicaid reimbursement, Managed Care Organization contracts, and health system reinvestment.9 Comprehensive screening and connection programs have used federal funding through multiple grant programs, including the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, and the Preschool Development Grant (PDG).10,11 States support comprehensive screening and connection programs through various funding streams, including taxes, public health funds, and general funds, as well as local and county funds.12,13

WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO MORE EFFECTIVELY IMPLEMENT COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS?

Over the last year, two states–Connecticut and New Jersey–took legislative action to provide comprehensive screening and connection programs statewide. Connecticut passed a bill that allocates $8 million of the state’s American Rescue Plan Act (ARPA) funds to implement a universally available program that is modeled on Family Connects. New Jersey appropriated $2.75 million to launch a statewide program that is also based on the Family Connects model. Oregon passed similar legislation in 2019 to implement the Family Connects model across the state, and a group of eight agencies and communities are currently participating in the early adoption phase of the initiative.

In addition to legislative progress, states have made significant financial investments to support comprehensive screening and connection programs. In 2021, the Governor of Maryland and the Maryland Department of Health (DOH) initiated a maternal and child health care initiative, which includes the expansion of HealthySteps in the state. The $72 million initiative from the Governor’s office will be funded by the Maryland Health Services Cost Review Commission, Maryland DOH Public Health Services, and Medicaid.

California passed and signed into law its FY21-22 state budget which includes $800 million (half of those funds are from the federal government) to create a new dyadic care benefit for Medi-Cal enrollees. When implemented, children and families with Medi-Cal insurance will be able to access dyadic care models, including the HealthySteps model, that address parent and child health together.

HOW DO COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS VARY ACROSS STATES?

States Vary in Whether they Implement Evidence-Based Comprehensive Screening and Connection Programs, and in How Many Families Are Served

HealthySteps is the largest of the three program models; in early 2020, it offered services in 24 states. New York has more HealthySteps sites than any other state, with 43 sites that provide access to services to nearly 10% of infants and toddlers across the state. Five other states (Arizona, California, Colorado, Florida, and North Carolina) have more than 10 HealthySteps sites in their state, but in most states relatively few infants and toddlers have access to the program. As of early 2020, 15.5% of infants and toddlers in Colorado have access to HealthySteps, which is the highest percentage in the country. With the exception of New York and North Carolina, in which approximately 10% of infants and toddlers have access to the program, in other states, fewer than 5% of children under age 3 have access to the evidence-based program model.

As of 2019, Family Connects offered its program in 12 states, but this number of states is expanding rapidly. North Carolina has the longest-running and most robust Family Connects program in the country, and it serves approximately 5% of new parents and their babies. In the other states, fewer than 1% of newborns receive the program.

DULCE is the smallest program and served approximately 750 families across sites in California, Florida, and Vermont in 2019, but is expanding quickly (Wisconsin, Kentucky, Michigan, Mississippi, New Jersey, and Rhode Island are all home to 2020 implementation sites).14

To date, only California offers all three evidence-based program models to families: DULCE, Family Connects, and HealthySteps, although the program models are offered in different communities across the state.

Several States Offer Alternative Models That Do Not Meet Our Definition of Comprehensive Screening and Connection Programs

Some states have created their own home-grown models that may share similar goals to DULCE, Family Connects, and HealthySteps. The state models have not been evaluated to the same extent as these evidence-based models, but they may meet the specific needs of the state. For example, Welcome Baby is available in 13 Los Angeles County hospitals in California, and provides universal prenatal and postpartum home visits to families.

New Mexico created First Born, a universal home visiting program that offers up to 40 prenatal and postpartum visits for first-time parents with children up to age 3. The state-supported program has expanded to 15 counties.

Rhode Island’s Department of Health has a nurse visitation program, First Connections, accessible to families and caregivers with children up to age 3. First Connections has expanded statewide.

Iowa has an alternative model, 1st Five Iowa, which is a partnership between the state Department of Public Health and primary care providers. Providers universally screen children up to age 5 during well-child visits and refer children to a 1st Five Developmental Support Specialist for services. 1st Five Iowa is available in 88 of Iowa’s 99 counties.

Other state-based models may exist, and we are interested in learning more about the effectiveness of these programs.

Explore more of the New York Roadmap

  1. Hagan, J.F., Shaw, J.S. & Duncan, P.M. (Eds.) (2017). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics. https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx
  2. Daro, D., Dodge, K.A., & Haskins, R. (2019). Universal approaches to promoting healthy development: introducing the issue. The Future of Children, (29)1, 3-18. doi: 10.1353/foc.2019.0001
  3. Center for Child & Family Health. (n.d.). Family Connects Durham. https://www.ccfhnc.org/programs/family-connects-durham/
  4. Ermias, A., & Lee, J. (2020, June 5). DULCE: A multi-sector approach to addressing the social determinants of health during and beyond the COVID-19 pandemic. https://cssp.org/2020/06/dulce-a-multi-sector-approach-to-addressing-the-social-determinants-of-health-during-and-beyond-the-covid-19-pandemic/
  5. Zero to Three. (n.d.). What is HealthySteps? https://www.healthysteps.org/
  6. Dodge, K. A., Goodman, W. B., Murphy, R. A., O’Donnell, K., & Sato, J. (2013). Randomized controlled trial of universal postnatal nurse home visiting: Impact on emergency care. Pediatrics, 132(Supplement 2), S140–S146. S140–S146. https://doi.org/10.1542/peds.2013-1021M [Comprehensive Screening and Connection Programs Evidence Review Study A]
  7. Goodman, W. B., Dodge, K. A., Bai, Y., O’Donnell, K. J., & Murphy, R. A. (2019). Randomized controlled trial of Family Connects: Effects on child emergency medical care from birth to 24 months. Development and Psychopathology, 31(5), 1863–1872. https://doi.org/10.1017/S0954579419000889 [Comprehensive Screening and Connection Programs Evidence Review Study C]
  8. Caughy, M. O., Miller, T. L., Genevro, J. L., Huang, K.-Y., & Nautiyal, C. (2003). The effects of HealthySteps on discipline strategies of parents of young children. Journal of Applied Developmental Psychology, 24(5), 517–534. https://doi.org/10.1016/j.appdev.2003.08.004 [Comprehensive Screening and Connection Programs Evidence Review Study H]
  9. Caughy, M. O., Huang, K.-Y., Miller, T., & Genevro, J. L. (2004). The effects of the HealthySteps for Young Children Program: Results from observations of parenting and child development. Early Childhood Research Quarterly, 19(4), 611–630. https://doi.org/10.1016/j.ecresq.2004.10.004 [Comprehensive Screening and Connection Programs Evidence Review Study I]
  10. US Administration for Children & Families. (n.d). Preschool Development Grant birth to five: A synthesis of funded applications. https://www.acf.hhs.gov/sites/default/files/documents/ecd/preschool_development_grant_birth_through_five_synthesis_report_07_14.pdf
  11. National Home Visiting Resource Center. (n.d.) Models. https://nhvrc.org/about-home-visiting/models/
  12. A. MacDonald, personal communication, June 16, 2021.
  13. Zero to Three. (2019). Funding HealthySteps: Site and system snapshots. https://www.healthysteps.org/article/funding-snapshots-detail-variety-of-financing-options-for-sites-127
  14. P. Hampton, personal communication, March 16, 2021.