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 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. 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.
Search the Prenatal-to-3 Policy Clearinghouse for an ongoing inventory of rigorous evidence reviews, including more information on evidence-based home visiting programs
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 inconsistent 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 lack of robust 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.
For more information on what we know and what we still need to learn about evidence-based home visiting programs, see the evidence review on evidence-based home visiting programs.
WHAT ARE THE KEY POLICY LEVERS TO IMPLEMENT EVIDENCE-BASED HOME VISITING 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 home visiting programs to all of the families who need the services. States vary considerably in the program models they implement and the funding streams states access to support their programs, such as Medicaid.
The key policy lever to more effectively provide home visiting program services is to:
- Use Medicaid to fund evidence-based home visiting programs that focus on parenting skills.
This key policy lever and the variation in state implementation is discussed in greater detail below.
States Can Choose From 16 Evidence-Based Home Visiting Program Models to Enhance Parenting Skills
The Home Visiting Evidence of Effectiveness (HomVEE) project thoroughly reviews early childhood home visiting programs that serve families with pregnant people and their children from birth to age 5. Program models are designated as evidence-based if they meet the rigorous HomVEE criteria for evidence of effectiveness.
HomVEE identifies 20 evidence-based program models as having favorable impacts on parenting skills. One program, Early Start (New Zealand) does not operate in the US, and another, the Home Instruction for Parents of Preschool Youngsters (HIPPY), serves children between the ages of 3 and 5. Additionally, Healthy Steps and Family Connects are considered “low touch” in service delivery, and thus more closely align with comprehensive screening and connection programs than evidence-based home visiting programs. The remaining 16 evidence-based home visiting program models listed below are designed for pregnant women or infants and toddlers, have a significant impact on improving parenting skills, are “high touch,” and operate in the US:
- Attachment & BioBehavioral Catch-up,
- Early Head Start-Home Based Option,
- Family Check-Up for Children,
- Family Spirit,
- Healthy Beginnings,
- Healthy Families America (HFA),
- Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT),
- Maternal Early Childhood Sustained HV Program (MESCH),
- Maternal Infant Health Outreach Worker (MIHOW),
- Nurse-Family Partnership,
- Oklahoma’s Community-Based Family Resource and Support (CBFRS) Program,
- Parents as Teachers,
- Play and Learning Strategies (PALS) – Infant,
- Promoting First Relationships – Home Visiting Intervention Model,
- Video-Feedback Intervention to promote Positive Parenting-Sensitive Discipline® (VIPP-SD),
- Video-Feedback Intervention to promote Positive Parenting (VIPP)
Different types of home visiting models allow states the flexibility to choose program models that 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 the Maternal, Infant, and Early Childhood Home Visiting (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. State funding streams include state general revenue, Children’s Trust Funds, tobacco settlements and taxes, and money from states’ cannabis accounts. By allocating additional resources beyond federal MIECHV funds, states can support programs and expand the reach of services.
Key Policy Lever: Medicaid funding promotes the use of evidence-based programs with favorable impacts on parenting
States use their Medicaid dollars in a variety of ways to support home visiting. 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 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. 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 October 2023, 28 states use Medicaid as a funding source for home visiting. Of these 28 states, 16 states’ Medicaid funding promotes the use of evidence-based parenting programs specifically. Delaware became the 16th state earlier this year when the state received federal approval to add coverage of services provided by Healthy Families America and Nurse-Family Partnership to its 1115 demonstration waiver. Kentucky uses Medicaid funding to implement Health Access Nurturing Development Services (HANDS), which is an evidence-based model but has not been proven to impact parenting.
HOW DOES ACCESS TO EVIDENCE-BASED HOME VISITING VARY ACROSS STATES?
States vary considerably in the amount and type of investments they make in home visiting programs, which leads to variation in the percentage of children under age 3 who are served. The National Home Visiting Resource Center (NHVRC) collects data from most evidence-based program models to describe the models that are implemented in each state and the number of children under age 3 that are served by each program model.14 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.15
According to data from NHVRC, 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 evidence-based home visiting programs in 2021 ranged from 27.8% in Rhode Island to only 0.8% in Nevada. Iowa served 31.2% of families with young children in home visiting programs, but the data provided include all families served by programs in the state, not only those served by evidence-based programs. Five states, excluding Iowa, serve more than 15% of their eligible prenatal-to-3 population, but 11 states serve less than 5%.
For more information on the state policy levers that may help improve parenting through evidence-based home visiting programs see our State Policy Lever Checklists.
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 fund and implement their home visiting programs. Over the last year, several states took legislative action to enhance their home visiting services. Lawmakers in Utah and Georgia appropriated funds for pilot programs to expand home visiting in their states and required a follow up report with recommendations for expanding programs statewide.
Utah lawmakers appropriated $10.5 million in TANF funds for a three-year pilot to create an updated home visiting system that serves more families with more services. Georgia’s pilot program is aimed at providing home visiting in at-risk and underserved rural communities during pregnancy and early childhood and is funded with $1.689 million in state general revenue. Lawmakers in both states did not include information on evaluation in the bills.
Illinois lawmakers codified the state’s existing evidence-based home visiting program that is run through the Department of Human Services in statute. The bill outlines that the department will follow MIECHV guidelines with eligibility and implement research-based programs. Legislators also allocated an additional $5 million in the FY 2024 budget to expand evidence-based home visiting programs.
Several additional states increased funding for home visiting programs. For example, Alaska increased funding for Early Learning Coordination, which includes home visiting programs and Head Start among other programs, by over $1.5 million. Florida lawmakers included $1 million in non-recurring general funds to the Nurse-Family Partnership program model for sustainability and expansion activities. Arizona appropriated $2.5 million to support the Nurse-Family Partnership program in the Strong Families Arizona Home Visiting System, and Indiana sustained increases for the Nurse-Family Partnership model that were made during the legislature’s 2022 special session.
Additionally, Missouri appropriated $279,102 of the Coronavirus State Fiscal Recovery funds to the Children’s Trust Fund Board for a pay-for-outcomes program designed to enhance the effectiveness of evidence-based home visiting programs serving high risk families. Rhode Island appropriated $6.9 million in state funding for home visiting programs, early intervention, and screening programs in response to declining enrollment and to give bonuses to providers hitting targets. Washington increased funding for home visiting programs by $8.56 million and earmarked the money to support wages and to create more equity in contracting among the home visiting workforce.
One state removed the requirement that home visiting funds go toward evidence-based programs. Texas lawmakers enacted a bill to repeal the state code that required 75% of funding for home visiting and other prevention and early intervention services be used for evidence-based models and the remaining funds for evidence-informed interventions. Contingent on this bill passing, lawmakers appropriated an additional $65 million over FY 2024 and FY 2025 for home visiting programs.
Only the District of Columbia introduced legislation this year to pursue Medicaid funding for home visiting programs. Council members introduced legislation to require Medicaid, the DC Healthcare Alliance, and the Immigrant Children’s program to cover and reimburse eligible home visiting services that are evidence-based, but the bill did not pass.
Notes and Sources
- Sandstrom, H. (2019). Early childhood home visiting programs and health. Health Affairs. https://www.healthaffairs.org/do/10.1377/hpb20190321.382895/full/
- Bronfenbrenner, U. (1992). The ecology of human development. In R. Vasta (Ed.) Six Theories of Child Development (pp. 187–249). London: Kingsley Publishers
- Sweet, M. A. & Appelbaum, M. I. (2004). Is home-visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75(5), 1435–1456. https://doi.org/10.1111/j.1467-8624.2004.00750.x
- National Scientific Council on the Developing Child. (2015). Supportive relationships and active skill-building strengthen the foundations of resilience [Working paper no.13]. https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2015/05/The-Science-of-Resilience2.pdf
- Nievar, M. A., Van Egeren, L. A., & Pollard, S. (2010). A meta-analysis of home visiting programs: Moderators of improvements in maternal behavior. Infant Mental Health Journal, 31, 499–520. https://doi.org/10.1002/imhj.20269 [Evidence-Based Home Visiting Evidence Review Study D]
- Sweet, M. A. & Appelbaum, M. I. (2004). Is home-visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75(5), 1435–1456. https://doi.org/10.1111/j.1467-8624.2004.00750.x
- Casillas, K. L., Fauchier, A., Derkash, B. T., & Garrido, E. F. (2016). Implementation of evidence-based home visiting programs aimed at reducing child maltreatment: A meta-analytic review. Child Abuse and Neglect, 53, 64–80. https://doi.org/10.1016/j.chiabu.2015.10.009 [Evidence-Based Home Visiting Evidence Review Study A]
- Lee, H., Crowne, S. S., Estarziau, M., Kranker, K., Michalopoulos, C., Warren, A., Mijanovich, T., Filene, J., Duggan, A., & Knox, V. (2019). The effects of home visiting on prenatal health, birth outcomes, and health care use in the first year of life: Final implementation and impact findings from the Mother and Infant Home Visiting Program Evaluation – Strong Start (OPRE Report #2019-08). Office of Planning, Research & Evaluation. https://www.acf.hhs.gov/opre/resource/effects-home-visiting-prenatal-health-birth-outcomes-health-care-first-year-final-implementation-impact-findings-strong-start
- Filene, J. H., Kaminski, J. W., Valle, L. A., & Cachat, P. (2013). Components associated with home visiting program outcomes: A meta-analysis. Pediatrics, 132 Suppl 2 (0 2), S100–S109. https://doi.org/10.1542/peds.2013-1021H [Evidence-Based Home Visiting Evidence Review Study C]
- Sweet, M. A. & Appelbaum, M. I. (2004). Is home-visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75(5), 1435–1456. https://doi.org/10.1111/j.1467-8624.2004.00750.x
- Casillas, K. L., Fauchier, A., Derkash, B. T., & Garrido, E. F. (2016). Implementation of evidence-based home visiting programs aimed at reducing child maltreatment: A meta-analytic review. Child Abuse and Neglect, 53, 64–80. https://doi.org/10.1016/j.chiabu.2015.10.009 [Evidence-Based Home Visiting Evidence Review Study A]
- Filene, J. H., Kaminski, J. W., Valle, L. A., & Cachat, P. (2013). Components associated with home visiting program outcomes: A meta-analysis. Pediatrics, 132 Suppl 2 (0 2), S100–S109. https://doi.org/10.1542/peds.2013-1021H [Evidence-Based Home Visiting Evidence Review Study C]
- Filene, J. H., Kaminski, J. W., Valle, L. A., & Cachat, P. (2013). Components associated with home visiting program outcomes: A meta-analysis. Pediatrics, 132 Suppl 2 (0 2), S100–S109. https://doi.org/10.1542/peds.2013-1021H [Evidence-Based Home Visiting Evidence Review Study C]
- NHVRC does not include service data from the following evidence-based programs that impact parenting: Family-Check Up, Healthy Beginnings, Healthy Steps, Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT), Oklahoma’s Community-Based Family Resource and Support Program, and Promoting First Relationships.
- 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) from 2021as the numerator, and the Census Bureau’s 2019-2021 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).
