Voluntary parenting programs vary in format, ranging from one-on-one to group-based parent education programs, and they differ in the specificity of their goals and target populations. Some programs target specific changes in parenting or child behaviors, whereas other programs target general improvements in child and family wellbeing. Other programs target families with specific risk factors (e.g., parents with low income, teen parents) or identified problems (e.g., behavioral problems in children), and others enroll families more universally. The theoretical underpinnings and evidence of effectiveness for parenting programs also vary widely.B
Home visiting programs, which provide parents with in-home support and education through a trained professional (e.g., nurse or social worker) or paraprofessional, have a growing evidence base and have expanded rapidly across the United States over the last decade.16 Although home visiting programs are only one model of programmatic support available to parents, they have the most robust history as a state-based investment in supporting parents and children, and are the focus of this review.
Since 2010, the federal Maternal, Infant, and Early Childhood Home Visiting program (MIECHV) has funded states, territories, and tribal entities to develop and implement evidence-based, voluntary home visiting programs for at-risk and high-priorityi populations.2 State investments in home visiting programs predate MIECHV (47 statesii funded home visiting programs prior to MIECHV), but data and tracking of states’ home visiting programs were poor.3 In Fiscal Year 2010, states made approximately $1.4 billion available for home visiting programs but could not account for the use of more than 40 percent of funds, nor did states provide adequate oversight to ensure program quality or require the use of program models with documented effectiveness.3
The MIECHV mandate to implement evidence-based home visiting programs brought the importance of evidence-based practice to the forefront of public policy and demonstrated the importance of rigorous program evaluation for helping policy-makers make informed decisions.4,5 The designation “evidence-based” among home visiting programs has been defined and determined through the federally funded Home Visiting Evidence of Effectiveness (HomVEE) review.16 To date, HomVEE has identified 21 home visiting models as “evidence-based,” meaning the models have each demonstrated at least two favorable impacts in either randomized controlled trials (RCTs) or in studies with quasi-experimental designs (QEDs) rated to be of either high or moderate quality across measures of child and family wellbeing.B
Many home visiting programs have been evaluated with RCTs, an evaluation method that is recognized by the National Academies of Sciences, Engineering and Medicine as providing “the highest level of confidence” in program efficacy or failure (p. 2).4 Findings from an internally valid RCT indicate what could be expected from a program if the program were replicated exactly like the RCT, but neither the random assignment of participants into treatment and control groups nor the careful control of the research design required in an RCT are likely to occur when programs are replicated during scale-up. Thus, the extent to which findings from an RCT can be generalized to a larger and often different population and context at a later time is limited—an “evidence-based” designation shows promise, but it is no guarantee of program effectiveness when implemented on a large scale.23
Who Is Affected by Evidence-Based Home Visiting Programs?
In 2019, evidence-based home visiting programs were implemented in all states, the five major territories, 22 out of 574 tribal communities, and 52 percent of US counties, serving more than 298,000 families through 3.2 million home visits.6 However, US Census estimates suggest that, of the approximately 17.8 million pregnant women and families with children under 6 years old not yet in kindergarten in the US, approximately 8.9 million families meet at least one of the “high-priority” criteria, indicating that home visiting programs reach a small fraction of the families who might benefit from participation.6
No national dataset provides a demographic overview of access to evidence-based home visiting programs specific to the prenatal-to-3 period. However, the National Home Visiting Resource Center provides a yearly snapshot of the recipients of 10 HomVEE-recognized models broken out by demographic characteristics. In their sample, adult home visiting recipients were 61 percent White, 30 percent Hispanic (of all races), 23 percent Black, and approximately 16 percent multiracial or from other racial groups.6,iii Families that are American Indian/Alaska Native, Asian, or Native Hawaiian/Pacific Islander represent only 3 percent or fewer of home visiting recipients. This sample suggests that the receipt of home visiting services may be roughly proportional to the demographic distribution of the US population with slight over- or under-representation of some groups. More information is needed to understand the demographic distribution of access to home visiting, beyond just the receipt of home visiting services.
What Are the Funding Options for Evidence-Based Home Visiting Programs?
In 2018, the Bipartisan Budget Act reauthorized MIECHV and allocated $400 million per year through Fiscal Year 2022.2 MIECHV requires state maintenance of effort (MOE), which means that states must maintain existing levels of state spending on home visiting as a condition of receiving federal MIECHV funds. According to the US Government Accountability Office, from Fiscal Years 2016 through 2018, state-reported MOE spending varied from $0 (28 states) to more than $25 million.7 States can report $0 in MOE spending if “a state’s only home visiting spending was on programs that did not meet MIECHV criteria. State-reported MOE spending does not necessarily reflect all state spending on all home visiting services” (p. 9).7
According to the National Conference of State Legislatures (NCSL), states use a wide variety of funding sources to support home visiting programs. In FY2019, these sources included state general funds, federal MIECHV grants, the Title V Maternal and Child Health (MCH) Block Grant, tobacco settlements and taxes, Temporary Assistance for Needy Families (TANF), Medicaid, federal child welfare funds (e.g., through the Family First Prevention Services Act of 2018), the federal Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health) and private funds.9 It is not clear from the research what the optimal funding mechanism or level is, and the data available on how states are using funds often come from surveys, many of which do not include responses from all states. For example, only 21 states responded to the most recent NCSL survey.10
Additional federal funding for home visiting became available during the COVID-19 pandemic. In March of 2021, the American Rescue Plan provided a supplemental $150 million for home visiting programs through September 30th, 2022.26 As of May 2021, almost $40 million of those funds have been distributed to US states, territories, and tribal entities. The Department of Health and Human Services instructed states to use these funds for emergency supplies, such as food, water, and hand sanitizer, as well as home visitor training and technology to enable virtual home visits.25
Since the 1990s, states have used Medicaid to fund home visiting services, often combining Medicaid with other sources of funding.11 In 2016, the Centers for Medicare and Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA) provided guidance to states permitting them to use Medicaid funding to pay for home visiting when provided to Medicaid beneficiaries.12 In 2021, 23 states were using Medicaid through a variety of mechanisms (e.g., managed care, waivers) to fund home visiting. The most common mechanism is using a Medicaid State Plan Amendment (SPA) to apply the targeted case management (TCM) benefit.11
- The five targeting criteria for “high-priority” include: (a) having an infant, (b) income below the federal poverty level, (c) pregnant women and mothers under 21, (d) single/never married mothers or pregnant women, or (e) parents without a high school education.
- State counts include the District of Columbia.
- Of the 10 home visiting programs that provided racial and ethnic data for the National Home Visiting Resource Center 2020 Yearbook, nine programs reported demographic information for adult participants while one program reported demographic information solely for children and pregnant caregivers. This sample incorporates some of the largest evidence-based home visiting programs but it is not representative of home visiting receipt in the US as a whole.