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 it encourages providers to take a more holistic approach to the many factors affecting a child’s health and wellbeing.1 Addressing risk early is vital for creating a strong foundation for child development.
Based on families’ identified needs, programs connect families to necessary services and supports to address concerns. Support for families can include educational materials, additional developmental or health screenings, and connections to existing community resources such as mental health services and child care. 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 universal and, therefore, available and voluntary to all families in the service area, regardless of income or other eligibility criteria (it 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 evidence-based and 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 age 6 months.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
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 and may enhance optimal child health and development with positive impacts on emergency department visits and vaccination rates. 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
Comprehensive screening and connection programs may reduce racial and ethnic disparities in outcomes because of their emphasis on addressing social predictors of health,6 but the current evidence is insufficient in evaluating reductions in disparities. 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.7 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.8
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 between first and second interviews with participants.9,10 Additionally, families of different races and ethnicities may respond differently to program models because of their cultural values or beliefs that may affect parenting styles.11 More evidence is needed on which comprehensive screening and connection programs may be the most culturally appropriate and responsive to families. Future research should consider under which circumstances such programs can have the largest positive impact on reducing racial disparities.
HOW AND WHY DO COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS VARY ACROSS STATES?
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/or
- Have implemented a universal program with a similar design to one of the three evidence-based program models.
State Policy and Administrative Choices 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, in 2019, Oregon passed legislation to implement the Family Connects model statewide and passed legislation in the past year to set reimbursement rates for providers. Connecticut and New Jersey took initiative in 2021 to begin offering a universal nurse home visiting program modeled on Family Connects statewide. In the last year, Colorado also took initiative to fund a statewide Family Connects program.
HealthySteps is the largest of the three program models; As of 2021, it offered services in 25 states. New York has more HealthySteps sites than any other state, with nearly 50 sites that provide access to 8.7% of infants and toddlers across the state. Most HealthySteps states, however, offer services to relatively few infants and toddlers. In 20 of the 25 states offering HealthySteps, fewer than 5% of infants and toddlers have access to the program.
As of 2021, Family Connects offered its program in 12 states. North Carolina has the longest-running and most robust Family Connects program in the country (Family Connects started as Durham Connects serving families in Durham County, NC in 2008), and it serves 3.5% of new parents and their newborns across 6 sites. With the exception of North Carolina and Iowa, which serves 2.3% of new parents and their babies, in most other states, fewer than 1% of new families receive the program.
DULCE is the smallest program and served nearly 1,500 families across sites in California, Florida, and Vermont in 2021.
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.
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.12,13,14 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).15,16 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.17,18
Several States Offer Alternative Models That Do Not Meet Our Definition of Comprehensive Screening and Connection Programs
Some states have alternative connection program models that may share similar goals to DULCE, Family Connects, and HealthySteps and strive to support families and connect them to necessary community services. Alternative models have not been evaluated to the same extent as the three evidence-based models, but they may meet the specific needs of the state.
Help Me Grow is one example of an alternative model active in multiple states. Program implementation differs between states, but the larger focus of the program is to help families with young children make connections to community resources. Families can reach out to their local Help Me Grow site with questions and concerns to initiate services. First Born, started in New Mexico, is another program expanding nationwide. The universal home visiting program provides support, screening, and connection services to families with children under age 4. First Born operates in 15 counties in New Mexico and started a new site in Minnesota this past year.
Other alternative models work within one state or city, often working in tandem with state or local health departments. Welcome Baby is available in 13 Los Angeles County hospitals in California and provides universal prenatal and postpartum home visits to families and one additional hospital visit immediately following the birth. A separate program also called Welcome Baby operates in Tennessee through the state Department of Health. Every family with a newborn in Tennessee receives a packet from Welcome Baby in the mail with information on community services. Families are screened for child risks and some families receive additional outreach.
Hawaii created Healthy Start through the state Department of Health Maternal and Child Health Branch. Healthy Start supports at-risk families with newborns through home visits and connects those families with necessary community resources.
Iowa has an alternative model, 1st Five Iowa, which is a partnership between the state’s 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.
Health Access Nurturing Development Services (HANDS) is available to families in Kentucky with children under age 3. The goal of the program is to teach families about community resources. Families can receive home visits and are referred to the program by physicians, the health department, or community members.
Massachusetts started the Welcome Family program (modeled after Family Connects) through the state Department of Public Health that provides one nurse home visit to families with newborns up to eight weeks postpartum. Families are provided with education, support, and referrals to community resources. The program operates in five cities in the state, but only serves a maximum of 500 families per year.
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.
Other state-based models may exist, and we are interested in learning more about the effectiveness of these programs.
WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO MORE EFFECTIVELY IMPLEMENT COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS?
Over the last year, Colorado joined the list of states that have opted to launch statewide comprehensive screening and connection programs based on the Family Connects model. In 2022, Colorado used funding from the American Rescue Plan Act (ARPA) to work with the state intermediary, Illuminate Colorado, to begin implementing the universal program across the state in late 2022.
Previously, Connecticut, New Jersey, and Oregon passed legislation to create a statewide program with a structure similar to Family Connects. In 2021, Connecticut used $8 million of the state’s ARPA funds to launch their statewide program, and the state is currently starting the first pilot site for the program. Also in 2021, New Jersey appropriated $2.75 million to launch their statewide program. The state is currently working on implementation as part of the Nurture NJ awareness campaign. Both Connecticut and New Jersey have cited Family Connects in their implementation plans and intend to use the structure of Family Connects in their statewide program. Oregon passed similar legislation in 2019 to implement the Family Connects model across the state, and a group of nine counties are currently participating in the early adoption phase of the initiative. In the last year, Oregon passed legislation to clarify reimbursement rates for providers of the state’s comprehensive screening and connection program. Providers will now be reimbursed in full for the cost of providing the program and have multiple options for reimbursement methodology.
States can also make financial investments in alternative comprehensive screening and connection programs. For example, in the last year, New York dedicated $500,000 of state funds to Help Me Grow, which serves as a guide to community service providers for families seeking resources. New Mexico legislators passed a budget bill that included significantly increased funding for First Born, a universal home visiting program that offers prenatal and postpartum visits for first-time parents, but the bill was ultimately vetoed by the governor.