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 over the last couple of decades 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 Positive long-term child development is promoted through 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.3 In addition, 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, which potentially increases families’ engagement in the programs.6
Further increasing accessibility, many home visiting programs have added options for virtual sessions. The availability of virtual sessions, although not yet studied rigorously, makes home visiting an option even to those who may have opted out of traditional home visiting services because of personal or cultural preferences.
Rigorous Research Demonstrates Home Visiting Programs Build Parenting Skills
Many home visiting programs have been evaluated with randomized controlled trials across a range of child and family outcomes. Although rigorous research has examined the impact of home visiting on a range of outcomes, the scope of this review is intentionally limited to parenting outcomes, the policy goal for which the most evidence on home visiting exists.
16 Home Visiting Program Models are Designated as Effective at Enhancing Parenting Skills
The Home Visiting Evidence of Effectiveness (HomVEE) project thoroughly reviews early childhood home visiting programs that serve families with expectant and new parents and their young children. Program models are designated as evidence-based if they meet the rigorous HomVEE criteria for evidence of effectiveness. States must use the vast majority of the MIECHV funds they receive from the federal Health Resources & Services Administration (HRSA) on programs designated as evidence-based and can allocate a small portion to promising programs that will be evaluated.
HomVEE identifies 21 evidence-based program models as having favorable impacts on parenting skills. Two programs, Early Start (New Zealand) and Preparing for Life (Ireland) do not operate in the US, and another, the Home Instruction for Parents of Preschool Youngsters (HIPPY), has only been evaluated for its impacts on preschoolers. Additionally, HealthySteps 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), and
- Video-Feedback Intervention to promote Positive Parenting (VIPP).
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 AND FOR WHOM?
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 IS THE KEY POLICY LEVER TO INCREASE ACCESS TO 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 provide access to home visiting programs to all families who need the services. States vary considerably in the program models they implement and the funding streams they access, such as Medicaid, to support their programs.
The key state policy lever to increase access to home visiting program services is:
- Use Medicaid to fund evidence-based home visiting programs that focus on parenting skills.
Key Policy Lever: Use Medicaid to Fund Evidence-Based Home Visiting Programs with Favorable Impacts on Parenting
Although there are multiple avenues for states to support home visiting, components of home visiting programs may be covered by Medicaid funding. Additionally, because coverage of home visiting program services under Medicaid must be outlined in a state’s 1115 waiver or state plan amendment, there are consistent data sources to determine which states use Medicaid. Other funding options for evidence-based home visiting programs lack consistently available data on use by states.
States use their Medicaid dollars in a variety of ways to support home visiting. Home visiting is not a service that by itself is reimbursed by Medicaid, but components of the programs and services provided in 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 ways 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 2024, 18 states use Medicaid funding as a source for evidence-based home visiting programs that are proven to impact parenting. Kentucky also uses Medicaid funding to implement Health Access Nurturing Development Services (HANDS), which does not target parenting outcomes and has not been evaluated for impacts on parenting.
States Can Use a Variety of Funding Mechanisms to Improve Access to Home Visiting Programs
Beyond Medicaid, 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) program. States receive a base funding allotment based on the number of children in the state, if they appropriate at least the same level of state funding to home visiting as they did in either Fiscal Year 2019 or Fiscal Year 2021. Beginning in Fiscal Year 2024, states and jurisdictions are also eligible for matching funds on top of their base allotment.
States may use other federal funding streams to support home visiting as well, including Medicaid, Title V Maternal and Child Health Services Block Grant, Temporary Assistance for Needy Families (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.
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.
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. The most recently published Yearbook, for 2023, includes participation data from 2022.
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 (FPL).15
According to data from NHVRC, the reach of home visiting varies considerably across the US. With the exception of a handful of states, however, the reach is relatively small. The percentage of families with young children served by evidence-based home visiting programs in 2022 ranged from 27.3% in Rhode Island to only 0.4% in Vermont. Four states serve more than 20% of their eligible prenatal-to-3 population, but 11 states serve less than 5%.
WHAT PROGRESS HAVE STATES MADE IN THE LAST YEAR TO INCREASE ACCESS TO 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 support of evidence-based home visiting programs through new funding streams or increased spending on home visiting programs.
States Considered Including Evidence-Based Home Visiting in Medicaid
Louisiana introduced, and the District of Columbia enacted, legislation to support home visiting programs by adding home visiting to their state Medicaid programs. Lawmakers in the District of Columbia successfully enacted legislation this session to require the health care programs run by the District, including Medicaid, the DC HealthCare Alliance Program, and the Immigrant Children’s Program to cover and reimburse services provided by home visiting programs. The legislation requires that services be provided through an evidence-based program as defined by HomVEE. As of October 1, 2024, the District has not yet submitted its state plan amendment for federal review, which will allow for implementation. Additionally, legislators included $4.5 million in the Fiscal Year 2025 budget to provide a state match for Medicaid reimbursement and to cover any implementation costs.
Louisiana also introduced legislation this year to pursue Medicaid funding for home visiting programs, but the bill did not ultimately pass this session. The bill would have required the state to add home visiting services provided by evidence-based programs, as designated by HomVEE, to the state’s Medicaid state plan. It would have also required the state to set the reimbursement rate for home visiting to at least 95% of the reimbursement for targeted case management services under Medicare to ensure funding.
States Increased Non-Medicaid Funding Streams for Evidence-Based Home Visiting
Nebraska and Colorado bolstered their support for home visiting programs by adding new non-Medicaid funding streams or requiring increased funds from existing streams go to home visiting in statute. Virginia also increased funding for evidence-based home visiting programs through the appropriations process.
Nebraska enacted legislation to add evidence-based home visiting programs to the list of services that can be funded with the state’s Medicaid Managed Care Excess Profit Fund, which is made up of funds returned to the state from managed care organizations that exceed their medical loss ratio. Legislators then appropriated $1.4 million from this fund to home visiting for Fiscal Year 2025.
Colorado, on the other hand, enacted legislation to increase the percent of the state’s tobacco litigation funds that are earmarked for the Nurse Home Visitor Program fund, which primarily goes toward Nurse-Family Partnership. The Nurse Home Visitor Program will now receive 28.7% of these funds, up from 26.7% previously, and the legislation prohibits the reduction of other funding streams to offset this increase. Virginia also increased the state funds dedicated to evidence-based home visiting. The $5.2 million in state general revenue and $9.0 million in TANF will be used to draw down additional MIECHV funds.
States Expanded Programming, Stabilized the Home Visiting Workforce, and Created Referral Systems
Several states allocated additional funds to expand existing programs and support the home visiting workforce. Florida appropriated $2.0 million in general revenue funds to Healthy Families America for workforce stabilization efforts and $2.0 million for Nurse-Family Partnership to support expansion of the program in the state’s Fiscal Year 2025 budget. Similarly, Georgia allocated $1.1 million in new state funds to expand the state’s pilot to provide home visiting during pregnancy and early childhood. The pilot program received $1.7 million in total funding between the existing funds and additional appropriation. Additionally, Illinois increased funding for evidence-based home visiting by $5.0 million to expand access to programs and improve home visitor’s compensation.
Finally, New Mexico took action to continue its development of a coordinated intake and referral system for home visiting. With an additional $2.0 million in general funds, the Early Childhood Education and Care Department will create the online system that will be accessible to both internal and external parties to better connect families with services.
For more information on each state’s progress on evidence-based home visiting programs, find our individual state summaries under Additional Resources below (and here).
ADDITIONAL RESOURCES
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 2022 as the numerator, and the Census Bureau’s 2021-2022 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).
