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 in services 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, however 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 only 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 AND WHY DO EVIDENCE-BASED HOME VISITING 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 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/or
- Use state dollars or Medicaid to support home visiting services.
State Policy and Administrative Choices Affect the Implementation of 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.
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 estimate 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 in families with incomes less than 150% of the federal poverty level.14
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%.
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 Minnesota 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 Funds, 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. Other 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.
As of 2021, 23 states used Medicaid as a funding source for their home visiting programs. In the last year, Ohio included home visiting as a part of its targeted case management benefit in a State Plan Amendment, making them 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 action to enhance their home visiting services. In California, legislators strengthened the state’s home visiting programs by increasing the authorized amount for one-time, as needed payments to help families enrolled in home visiting programs purchase household items related to the care, health, and safety of the child. Previously these payments could not exceed $500, but beginning this year the payments may be up to $1,000.
Illinois established a new 3-year pilot program to provide additional resources, including home visiting services, to families with children under the age of 5 enrolled in the state’s Extended Family Support Program. Illinois’ Extended Family Support Program provides short-term services to relative caregiver families who are not involved in the formal child welfare system. The pilot program will be independently evaluated.
Several states increased funding for home visiting programs. For example, Rhode Island appropriated $5.5 million in state funding for home visiting programs, early intervention, and screening programs in response to declining enrollment. Additionally, Washington increased their annual appropriation for home visiting services by over $4 million. Arkansas appropriated $2 million in state funding for home visiting and early childhood programs administered by Save the Children, and New Hampshire appropriated $1 million, which may be used to support evidence-based programs such as home visiting programs, to family resource centers across the state.