Bringing Up Baby: January 2012

For new parents, home visits by trained professionals can make all the difference.

By Steffanie Clothier and Jack Tweedie

There’s nothing like becoming a new parent. The joys are great, but the demands are daunting, even for the well-prepared. For young, poor single parents—who often lack stable jobs, places to live or family support—the challenges can be overwhelming.

Since the 1990s, lawmakers have increasingly supported voluntary home visiting programs as a promising way to provide support for these families and a better chance of a good start for their children’s health, development and well-being.

Forty-six states and Washington, D.C., now fund some type of voluntary early childhood home visiting program, according to the Pew Center on the States. These programs send a nurse, social worker or other specially trained visitor to work with expecting women and new parents in their homes.

These trained professionals come—as often as weekly near the birth and less frequently as the child grows older—to teach interested parents how to provide good nutrition for their babies, deal with colicky ones, talk and interact in ways that stimulate babies’ brains, and avoid potential health risks. They help parents recognize and address special challenges, such as learning disabilities and developmental delays. They can refer moms with depression or substance abuse problems to counseling and other resources. And they answer the flood of questions that come as parents adjust to pregnancy and caring for the baby.

Rigorous evaluations of home visiting practices have shown programs that target families with particular challenges—such as first-time, teen or low-income parents or single moms—can reduce child abuse, improve parenting skills, and enhance children’s health and readiness for school.

Investments in these programs have produced significant returns through reduced spending on early childhood health care, child welfare, special education, grade retention and juvenile crime. Home visiting can reduce infant mortality, preterm births and emergency room visits. The Nurse Family Partnership program has shown the strongest results, with one study finding a 48 percent reduction in child abuse and cost-benefit research showing as much as a $5.70 benefit for every dollar spent.

“In times like these when we are cutting billions of dollars from our budget, we must invest our scarce resources where they will have the greatest return. Home visiting is such an investment,” says Washington Representative Ruth Kagi.

As is the case with many social programs, the strength of the research varies, and results are different among home visiting programs. In addition, there are an array of state and local home visiting programs that may be achieving good results for children and families but either have not been evaluated or have not been studied using the most rigorous methodologies.

For the past decade, many states have funded programs through a mix of state general fund money, federal welfare money, tobacco settlements and Medicaid. Lawmakers looked to invest in effective programs, but often lacked clear research when choosing among different approaches or evaluating locally developed strategies. They supported a variety of national, state or locally designed models that looked promising. Many programs are hybrids, using materials from national models with community members for home trainers and adjusting the frequency of visits to fit the community’s needs and funding. The recent focus on research-based evidence has led many state officials to re-examine these programs to ensure they meet the highest standards.

A Push From D.C.

In 2010, Congress established the five-year, $1.5 billion Maternal, Infant and Early Childhood Home Visiting Program, which provides grants to states and tribes to use on voluntary, home-based services for expecting and new parents. States were required to conduct a needs assessment, identify specific at-risk communities to target, and choose from among nine approved home-visiting models.

All 50 states, the District of Columbia, and five territories applied for the first $90 million, and only North Dakota opted out of the second-year formula funding of $125 million. Federal money increases to $350 million in the third year and $400 million in the fourth and fifth years. Most states also submitted applications for part of the $99 million in competitive grants that were awarded in September to 22 states. These competitive grants range from $1.1 million to $9.4 million a year.

The federal grants do not require new state matching funds, but states must maintain spending to be eligible, although states that made across-the-board cuts that reduced spending for home visiting have remained eligible. At least 75 percent of the federal money must be used to support evidence-based programs identified in the federal grant. In a nod to innovation, states may spend up to 25 percent of the federal money on promising programs that will be evaluated in the future.

States are required to track whether programs are:

• Improving maternal and child health.
• Reducing child abuse and neglect, injuries and emergency room visits.
• Improving children’s readiness for school and their achievement.
• Reducing crime or domestic violence.
• Improving family economic self-sufficiency.
• Improving the coordination and referrals for other community resources.

Not all legislators support seeking the federal money. The Florida Legislature originally voted not to apply for the money, in part because it is tied to federal health care reform.
Representative Denise Grimsley, chair of the Joint Legislative Budget Commission, said she did not want to accept the home-visiting grant because of the health-care law and because it was a case of “big government” assuming responsibilities that should rest with families. Legislators did accept the money in August when it became clear their decision would affect Florida’s eligibility for the Race to the Top Early Learning Challenge grant.

States Move Ahead

The federal home visiting initiative is being launched at a time when state policymakers are at very different points in how they envision their state services. Some lawmakers have moved ahead with setting goals for expansion and developing methods for directing funds to effective programs. Others have been able to use the planning and assessment period of the federal grant to identify the best next steps for their states.

In Louisiana, state officials identified needs and priorities for expansion. Resolutions passed by the Legislature in 2008 and 2009 established a Home Visiting Advisory Council that made recommendations for expanding the Nurse-Family Partnership from 15 percent of eligible families to 50 percent by 2014. Louisiana received $6.6 million in competitive grant funding that will enable them to expand more quickly.

“We know that the Nurse-Family Partnership works in Louisiana,” says Senator Mike Walsworth. “We can now use these [new] funds to reach more eligible mothers to transform the lives of children and families in Louisiana.”

In Washington, the Legislature enacted a requirement in 2009 that new money for home visiting be directed only to programs proven to be effective. The state also created a public-private matching fund to support expansion, training, improvements and evaluations. The federal home visiting money is being distributed to programs that meet the evidence-based standards in the federal law.

“Washington has worked with our business and philanthropy partners to be well-positioned for the federal funding,” says Kagi.

Iowa lawmakers inventoried their home visiting investments in 2007 and found almost a dozen different programs—including national and local models—spread across several state agencies. Without any evaluation of the local programs, it was difficult to determine whether they were making a difference. So agency officials decided to target the new federal money to two communities plus provide planning grants to others. It’s too early to say whether any local programs will be successful in gathering the evidence needed to be added to the list of approved models.

New Mexico, too, has several home visiting programs operating around the state, funded by the state as well as philanthropy. The initial federal home visiting money allowed the state to expand services in two communities and address needed improvements, such as developing a data system to track results and analyze progress. New Mexico received one of the competitive grants to develop a continuum of services, starting with screening for needs and including specialized treatment for those with significant challenges.

“Evidence-based home visiting is a critical part of our strategy to reduce poverty and improve outcomes for disadvantaged families,” says Senator John Sapien. “Increased federal funding will allow the home visiting strategy to reach more families and ultimately decrease the costs of some social programs.”

Legislators often have not been in the driver’s seat in applying for federal funds for home visiting but will be important players in the future. Legislators, who have funded the current array of state and local programs, will be in a position to take stock of existing appropriations and determine how best to ensure they are making investments in programs that make a difference for families.

Steffanie Clothier and Jack Tweedie track children and family issues for NCSL.