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 include behavioral and biological issues as well as 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 also encourages providers to take a more holistic approach to the many factors affecting 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 also key aspects of these approaches to address identified areas of need.2
3 Comprehensive Screening and Connection Program Models Have Been Rigorously Studied
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 Recruits Families at Birth in Participating Hospitals
Family Connects, a community-wide nurse home visiting program, offers enrollment to families at participating hospitals. Families that opt into the program receive approximately one to three home visits. 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 Connect to 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 AND FOR WHOM?
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.
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 Five rigorous studies assess subgroup effects by race or ethnicity, but evidence remains too scarce to draw conclusions about the ability of comprehensive and screening and connection programs to improve disparities in outcomes.
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 also 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 provide comprehensive screening and connection programs to all families.
We identified three key state policy levers that states can implement to increase participation of eligible families. The three state policy levers include:
- Establish a state goal to implement evidence-based comprehensive screening and connection programs statewide,
- Use Medicaid funding to support evidence-based comprehensive screening and connection programs, and
- Use direct state funding to support evidence-based comprehensive screening and connection programs.
As of October 1, 2024, five states have implemented all three key policy levers to increase access to comprehensive screening and connection programs. Colorado became the fourth state to do so this year, due to its expansion of Family Connects to more counties throughout the state. Vermont became the fifth state to do so this year, due to its goal to implement DULCE statewide.
Key Policy Lever: Establish a State Goal to Implement Evidence-Based 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.
Although setting a 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 start with temporary funding for small-scale implementation or use long-term funding to rollout a program over time; sustainable funding will be needed to extend the life of the statewide program.
As of October 1, 2024, seven states (Colorado, Connecticut, New Jersey, North Carolina, Ohio, Oregon, and Vermont) have a goal to implement, or have started to implement, comprehensive screening and connection programs that will eventually have statewide reach. Whereas statewide plans had been in progress in Connecticut, New Jersey, and Oregon previously, Colorado, North Carolina, Ohio, and Vermont all took steps towards implementing evidence-based comprehensive screening and connection programs statewide in the last year. Six states use the Family Connects model as a basis for statewide programs; only Vermont uses DULCE.
In 2021, Connecticut used $8 million of the state’s American Rescue Plan Act (ARPA) funds to launch its statewide program, and the state opened its first site in 2023. Connecticut is exploring sustainable funding to support its expansion beyond 2026.
Also in 2021, New Jersey appropriated $2.75 million to launch its statewide program, and in January 2024, the state launched Family Connects in five counties with plans to expand to six additional counties in early 2025.
In Oregon, which has been implementing statewide expansion since 2019, participation in Family Connects grew from 600 families in 2022 to more than 1,600 families in 2023. Colorado also used ARPA funding for the initial start-up of its statewide Family Connects expansion, and expanded from three counties to four counties in the last year. In its budget for Fiscal Year 2025, Colorado appropriated funding to continue the expansion of Family Connects to an additional 10 counties and to establish a Family Connects Universal Home Visiting Pilot.
Legislators in North Carolina allocated funding for Fiscal Year 2025 to expand Family Connects statewide. Also, Ohio Governor DeWine announced a plan to scale Family Connects statewide, beginning with the launch of a pilot program in 11 counties. These new sites will open in late 2024. Vermont is using federal Health Resources and Services Administration Transforming Pediatrics for Early Childhood agreement funds to expand the reach of DULCE statewide.
Key Policy Lever: Use Medicaid Funding to Support Evidence-Based 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. Currently, 21 states leverage Medicaid to support evidence-based comprehensive screening and connection programs. In the last year, five states (Arkansas, Kentucky, Mississippi, Rhode Island, and Vermont) began using Medicaid funding to support these programs.
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.
Key Policy Lever: Use Direct State Funding to Support Evidence-Based Comprehensive Screening and Connection Programs
Direct state funding can support the start-up or expansion of evidence-based comprehensive screening and connection program 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, 19 states use some type of direct state funding to support comprehensive screening and connection programs. Kentucky, Mississippi, and Rhode Island all launched DULCE this year, using direct state funding to support the program. Also, Nebraska began using direct state funding to support its Family Connects program in the last year.
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 reinvestments.13,14,15 Comprehensive screening and connection programs have also 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
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.
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 2023, it offered services in 24 states. New York has more HealthySteps sites than any other state, with over 50 sites that provide access to 9.6% of infants and toddlers across the state. Most HealthySteps states, however, offer services to relatively few infants and toddlers. In 18 of the states that offer HealthySteps and have service data available, fewer than 5% of infants and toddlers have access to the program.
As of 2023, Family Connects offered its program in 17 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 4.8% of new parents and their newborns across six sites. In 11 of the states that offer Family Connects, fewer than 3% of new families receive the program.
DULCE is the smallest program and served nearly 1,700 families across sites in California, Florida, Kentucky, Mississippi, Rhode Island, and Vermont in 2023. The program has grown considerably as three states (Kentucky, Mississippi, and Rhode Island) all launched the program in the last year.
Several States Offer Alternative Models That Do Not Meet Our Definition of Evidence-Based 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 31 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 in 1997, is another program expanding nationwide. The universal home visiting program provides support, screening, and connection services to families with children under age 4, and may include up to 40 home visits. First Born operates in nine counties in New Mexico and one location in Duluth, Minnesota.
Other alternative models work within one state or city, often in tandem with state or local health departments. For example, Welcome Baby is available in 13 Los Angeles County hospitals 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 through the state Department of Public Health. The program 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.
WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO INCREASE ACCESS TO COMPREHENSIVE SCREENING AND CONNECTION PROGRAMS?
Over the last year, several states took action to improve access to comprehensive screening and connection programs, specifically by initiating plans to expand evidence-based services statewide, using Medicaid to support programs, and directing state funding to support various programs, including alternative models.
3 States Expanded Comprehensive Screening and Connection Programs Statewide
In the last year, three states (Colorado, North Carolina, and Ohio) took steps to expand Family Connects statewide. Legislators in Colorado appropriated $2.8 million to expand Family Connects across 10 counties. The program had previously been piloted with American Rescue Plan funds in four counties. North Carolina legislators also allocated $52.4 million to expand Family Connects to local agencies statewide. Finally, in his 2024 State of the State address, Ohio Governor DeWine announced his intention to scale Family Connects statewide, with requests for funding in Fiscal Year 2025-26 and the launch of a pilot program in 11 counties.
Three states that previously initiated plans to expand Family Connects statewide saw steady growth in their numbers of sites and families served. Oregon, which initially enacted legislation in 2019 to expand Family Connects across the state saw participation across sites grow from 600 families in 2022 to more than 1,600 families in 2023. Connecticut, which began steps to implement Family Connects statewide in 2021 using ARPA funding, opened its first site in Bridgeport in late 2023. Finally, Family Connects launched in five New Jersey counties in January 2024, with plans to expand to six additional counties in early 2025.
Other states took steps to study statewide implementation of comprehensive screening programs. For example, Louisiana enacted legislation to create a Postpartum Newborn Nurse Home Visiting Task Force to study the implementation of Family Connects, including potential Medicaid and private insurance funding.
5 States Began Using Medicaid Funding to Support Evidence-Based Comprehensive Screening and Connection Programs
Over the last year, states saw growth across their comprehensive screening and connection programs. Five states (Arkansas, Kentucky, Mississippi, Rhode Island, and Vermont) began using Medicaid funding to support evidence-based comprehensive screening and connection programs. Arkansas began using Medicaid to support HealthySteps, and the other four states began using Medicaid to support DULCE. States that offer the HealthySteps model, especially, experienced growth in the number of sites and families served as a result of using Medicaid funding, which can be more sustainable, to finance their programs.
For example, Arkansas began taking steps to offer a supplemental Medicaid rate for pediatricians and family doctors who offer HealthySteps in the last year. In Arkansas, families can access HealthySteps at seven sites across the state and the state expects to increase the reach of the program by the end of 2024. Connecticut is also exploring using Medicaid financing to provide more sustainable support for its statewide Family Connects program.
4 States Began Using Direct State Funding to Support Comprehensive Screening and Connection Programs, Including Alternative Models
Over the last year, four states began using direct state funding to support evidence-based comprehensive screening and connection programs. Kentucky, Mississippi, and Rhode Island all began using state funds to support their newly launched DULCE programs, and Nebraska began using state funding to support Family Connects.
States also invested in previously established alternative models in the last year. For example, New Mexico allocated funding to support its alternative comprehensive screening and connection program, First Born.
In addition, Massachusetts introduced legislation to expand universal postpartum home visiting across the state through an alternative, locally-developed, universal support model, Welcome Family. If passed, models such as Welcome Family would be eligible to be scaled statewide. As of October 2024, the legislature was still in session, and the bill had not passed. In August 2024, Massachusetts did enact a separate bill to overhaul maternal health care in the state. The bill directs the Department of Health to create a new program to provide universal home visiting and mandates insurance coverage for those services, which include at least one postpartum home visit.
For more information on each state’s progress on comprehensive screening and connection programs, find our individual state summaries under Additional Resources below (and here).
ADDITIONAL 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.