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
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, improve maternal mental health, and may enhance optimal child health and development outcomes such as vaccination rates and emergency department visits. 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 five 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
A randomized controlled trial (RCT) of Family Connects demonstrated reductions in disparities between Black and White families in maternal anxiety, maternal depression, and child emergency medical care. The study also found a reduction of disparities in child emergency medical care and child maltreatment investigations.9 More research is needed to understand the different results in the multiple Family Connects studies.
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.10,11 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.
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.
WHAT ARE THE KEY POLICY LEVERS TO SUPPORT COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS?
In contrast to the evidence for the four 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 families.
We identified three key policy levers that states can implement to increase participation of eligible families. The policy levers include:
- Establish a state goal to implement comprehensive screening and connection programs statewide,
- Use Medicaid funding for the programs, and
- Provide state funding for the evidence-based programs.
Each policy lever and the variation in state implementation is discussed in greater detail below.
Key Policy Lever: States Establish a Goal to Implement Comprehensive Screening and Connection Programs Statewide
In many states, comprehensive screening and connection programs are implemented at the local or community level, but states can implement a statewide initiative to ensure access is extended to regions and communities where families can benefit the most.
As of October 1, 2023, three states (Connecticut, New Jersey, and Oregon) have a goal to implement or are starting to implement comprehensive screening and connection programs that will eventually have statewide reach. All three states use the Family Connects model as a basis for statewide programs.
In 2021, Connecticut used $8 million of the state’s American Rescue Plan Act (ARPA) funds to launch their statewide program, and the state is currently running 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. 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. Providers in Oregon are reimbursed in full for the cost of providing the program and have multiple options for reimbursement methodology.
Although setting a state goal to implement comprehensive screening and connection programs statewide is an important step, statewide initiatives typically start with legislation and require significant funds and investment to launch. States can use long-term funding to rollout a program over time or start with temporary funding for small-scale implementation; further funding will be needed to extend the life of the statewide program.
Long-term sustainable funding for comprehensive screening and connection programs may help reduce racial and ethnic disparities in outcomes because of the programs’ emphasis on addressing social predictors of health.
Key Policy Lever: States Use Medicaid Funding to Support Comprehensive Screening and Connection Programs
Comprehensive screening and connection programs rely on a variety of funding mechanisms. A key funding stream states can use to support programs is Medicaid. States can allocate Medicaid funds to support programs or states can pass legislation or take administrative action to set and increase Medicaid reimbursement rates for eligible providers.
Comprehensive screening and connection programs can bill Medicaid for preventive services if an approved State Plan Amendment (SPA) is in place. SPAs can also cover targeted case management services to allow programs to bill Medicaid for screenings and facilitation of referral services. Finally, Medicaid coverage can be expanded by contracts with Medicaid Managed Care Organizations to bill for services related to comprehensive screening and connection programs.
Currently, 21 states leverage Medicaid to support comprehensive screening and connection programs.
Our primary funding information for Family Connects has been updated this year, but we were unable to update funding information for the HealthySteps and DULCE programs, therefore, for those programs we reference the funding sources from our last update in 2021 throughout the Roadmap.
Key Policy Lever: States Provide State Funding to Support Comprehensive Screening and Connection Programs
Providing state funds support comprehensive screening and connection programs by supporting the start up or expansion of sites. States may use general funds, revenue from taxes dedicated to early childhood development and health programs (e.g., property or tobacco taxes), and state agency funding (e.g., prevention and family services departments). Currently, 20 states use some type of direct state funding to support comprehensive screening and connection programs.
Comprehensive Screening and Connection Programs Rely on Funding Sources Beyond Medicaid and Direct State Funding
In addition to Medicaid and direct state funding, DULCE, Family Connects, and HealthySteps are funded through federal and private support, including a combination of local government resources, foundation support, and health system reinvestment.13,14,15 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).16,17 Programs also rely on local and county general funds or public health funds.18,19
HOW DOES ACCESS TO COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS VARY ACROSS STATES?
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 the number of sites available for families. Only one state, California, offers all three evidence-based comprehensive screening and connection programs.
HealthySteps is the largest of the three program models. As of 2022, it offered services in 23 states. New York has more HealthySteps sites than any other state, with nearly 50 sites that provide access to 9.3% of infants and toddlers across the state. Most HealthySteps states, however, offer services to relatively few infants and toddlers. In 19 of the 23 states that offer HealthySteps, fewer than 5% of infants and toddlers have access to the program.
As of 2022, Family Connects offered its program in 16 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 4.5% of new parents and their newborns across six sites. In 10 of the 16 states that offer Family Connects, fewer than 1% of new families receive the program.
DULCE is the smallest program and served over 1,500 families across sites in California, Florida, and Vermont in 2022. Vermont continues to expand its number of sites. DULCE is currently opening new sites in Kentucky, Mississippi, and Wisconsin.
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.20
Help Me Grow is one example of an alternative model that is 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, which 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 nine counties in New Mexico and one location in Minnesota centered in Duluth. The program model is currently undergoing rigorous evaluation to determine its effectiveness.
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 initiative also called Welcome Baby operates in Tennessee through the state Department of Health. Every family with a newborn in Tennessee receives a packet 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. 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.
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 8 weeks postpartum. Families are provided with education, support, and referrals to community resources. The program operates in four cities in the state and served nearly 1,500 families in 2022.
Other state-based models may exist, and we are interested in learning more about the effectiveness of these programs.
For more information on the state policy levers to help maximize the effectiveness of comprehensive screening and connection programs see our State Policy Lever Checklists.
WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO MORE EFFECTIVELY IMPLEMENT COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS?
In the last year, states have considered funding allocations and legislation to support comprehensive screening and connection services. New Jersey allocated $500,000 this year to establish a program for enhanced Medicaid payments for well-child and sick visits claims at HealthySteps sites. Arkansas and Oregon also introduced bills regarding Medicaid reimbursement, but the bills did not pass.
Three states allocated funding for comprehensive screening and connection programs in their budgets last year. Florida allocated over $700,000 for the Cayuga Centers HealthySteps Program Expansion, Oregon allocated nearly $6 million to the Oregon Health Authority to continue the expansion of a statewide Family Connects program, and Illinois allocated $1.6 million from general funds for Family Connects. Connecticut also passed legislation to formally place the statewide Family Connects program in statute.
Massachusetts introduced two bills in the last year relating to the expansion of access to universal postpartum home visiting services that could include an evidence-based comprehensive screening and connection program. As of October 1, 2023, the legislature was still in session, and the bills had not passed.
States can also make financial investments in alternative comprehensive screening and connection programs. For example, in the last year, Florida allocated over $1.8 million from general revenue and nearly $2.6 million in nonrecurring funds to Help Me Grow, which serves as a guide to community service providers for families seeking resources.
Notes and Sources
- 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
- 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
- Center for Child & Family Health. (n.d.). Family Connects Durham. https://www.ccfhnc.org/programs/family-connects-durham/
- 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/
- Zero to Three. (n.d.). What is HealthySteps? https://www.healthysteps.org/
- 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
- 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]
- 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]
- Dodge, K. A., Goodman, W. B., Bai, Y., Best, D. L., Rehder, P., & Hill, S. (2022). Impact of a universal perinatal home-visiting program on reduction in race disparities in maternal and child health: Two randomised controlled trials and a field quasi-experiment. The Lancet Regional Health – Americas, 15, 100356. https://doi.org/10.1016/j.lana.2022.100356
- 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]
- 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]
- 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]
- K. Friedman, Family Connects International, personal communication, March 30, 2023.
- 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
- P. Hampton, personal communication, February 26 to June 16, 2021; S. Johnson and B. Holmes, personal communication, April 12, 2021
- 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
- National Home Visiting Resource Center. (n.d.) Models. https://nhvrc.org/about-home-visiting/models/
- K. Friedman, Family Connects International, personal communication, March 30, 2023.
- 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
- For additional information on alternative comprehensive screening and connection programs, please refer to Methods and Sources.
