Report Early Childhood Home Visiting: What legislators need to know

Introduction

Over the last decade, breakthroughs in brain research have crossed over into the realm of policymaking. Driven by a stream of new findings related to early brain development, an increasing number of lawmakers from across the political spectrum are now focused on the immediate and lasting significance of early childhood experiences. How children’s brains develop, particularly in their first five years, determines how they see and respond to the world.

Infants and toddlers require supportive and nurturing parents and caregivers to feel secure and thrive. For this to happen, children need the presence of at least one stable and caring adult, and most often this happens naturally in the context of a birth or adoptive family. But that’s not always the case. Humans have varying capacities to parent. Some lack the support of family or friends or are living in unstable conditions, struggling financially, fighting addiction or confronting other significant challenges. As a result, children are growing up in environments that range from safe, stable and nurturing to abusive, chaotic and neglectful.

Recognizing parents as their child’s first, and often best, teachers is the foundation of home visiting. At the same time, all parents need guidance and support—especially single, first-time and low-income mothers—and many do not have access to those things through family and friends. Voluntary home visiting is a vehicle to connect parents and their young children to resources that facilitate positive parenting and healthy child development.

In response to this growing body of scientific research about what young children need and how to provide it, some state policymakers are promoting home visiting to link pregnant women with prenatal care, encourage strong parent-child attachment and foster positive child health and development. High-quality home visiting programs have been shown to improve outcomes for children and families, particularly teen or single parents, new mothers experiencing depression and families lacking social and financial supports.

Rigorous evaluations of home visiting programs have revealed positive outcomes related to birth, children’s health, school readiness, parenting skills, and a reduction in child abuse and neglect. According to the American Academy of Pediatricians, home visiting can increase school readiness, decrease child maltreatment and increase family economic stability. A 2017 report showed some evidence-based home visiting models mitigate adverse childhood experiences (ACEs) and prevent intergenerational ACEs. Research also indicates that home visiting can help lay the foundation for resilience and healthy development for families facing multiple socio-demographic stressors and lacking financial resources and social supports.

This brief is intended to help state policymakers make informed decisions about home visiting policies in their states.

Home Visiting Overview

Home visiting is a family support strategy with a history dating back more than 100 years. Along the way, a variety of models with varying degrees of efficacy have emerged, and home visiting began to attract support from private donors and local, state and federal governments. Since the 1990s, lawmakers have increasingly promoted voluntary home visiting programs to bolster families and provide a strong start for children. In 2010, with bipartisan support, the federal government established the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV), leading to a significant expansion of home visiting in states, territories and tribal communities.

Today, early childhood home visitors address individual family needs, such as developmental concerns and caregiver mental health or substance abuse, by partnering with families to establish positive parenting practices and parent-child relationships. Because these programs simultaneously engage with primary caregivers and their child, home visiting is often considered a two-generation or whole-family approach.

Home Visiting Models

Models vary in outcome, duration and frequency of visits and intended target population. Some begin in pregnancy; others during the first year of a child’s life. Some last two years, while others may last up to age 6 or the start of kindergarten. Potential outcomes include: improvements in maternal and newborn health; prevention of child injuries, abuse, neglect or maltreatment; reduction in emergency department visits; increased school readiness and achievement; lower incidence of crime or domestic violence; improvements in family economic self-sufficiency; and better coordination of and referrals for other community resources and supports.

The U.S. Department of Health and Human Services currently recognizes 18 evidence-based home visiting models as eligible for federal funding. All models must have at least three years of operating history, provide implementation support to provider organizations and trainings for home visitors, and specify minimum requirements for frequency of visits.

While, at their core, all early childhood home visiting models are designed to improve outcomes for children, they focus on different outcomes (e.g., school readiness or family violence prevention) and employ different strategies and protocols for achieving those outcomes. Similarly, models with evidence of effectiveness in achieving one outcome may not have evidence showing effectiveness achieving other outcomes. The following table shows the domains in which home visiting models have verified evidence of effectiveness as determined by the Department of Health and Human Services Home Visiting Evidence of Effectiveness review.

Targeted and Universal Approaches

Home visiting approaches vary by target participant (e.g., serve first-time parents only, focus on healthy births, or target families at risk of child abuse or neglect), specific model and approach. However, all involve trained staff conducting a visit with a family. Depending on the model, the home visitor could be a nurse, social worker, professional or paraprofessional. Regardless of model, home visitors are trained to make referrals, share parenting strategies and encourage healthy activities (e.g., smoking cessation and breast feeding). Particularly with models that are targeted, a strong relationship between visitor and client is essential.

Some programs, including Parents as Teachers or Nurse-Family Partnership, are targeted to families meeting certain criteria such as income or number of previous pregnancies. Others are universally available within defined geographic areas. Family Connects is a community-wide universal nurse home visiting program for parents of newborns. It is based on the Family Connects Durham model piloted in Durham County, North Carolina. Family Connects operates in five states.

Is Home Visiting Effective?

Studies on the cost-effectiveness of home visiting programs have found a significant positive return on investment. For example, a study of one home visiting program, Home Instruction for Parents of Preschool Youngsters (HIPPY USA), found a return on investment of $1.80 for every $1 invested. A separate study found that the home visiting model Nurse-Family Partnership (NFP), designed specifically for first-time mothers, reduced Temporary Assistance for Needy Families (TANF) payments by 7% for nine years postpartum. Most of the savings is due to reduced child protective services costs, fewer children requiring special education or grade retention and lower criminal justice expenses.

Home Visiting Legislation

Following the passage of MIECHV in 2010, at least 23 states have passed home visiting legislation of their own. State legislatures are allocating funds and advancing legislation to help coordinate state-administered home visiting programs and strengthen the quality and accountability of those programs.

Some legislators are passing legislation to set program standards and expected outcomes. Others are allocating funds and providing legislative oversight of the state agencies. In addition, some are leading the way to develop comprehensive and connected early childhood systems that include high-quality child care, prekindergarten, early intervention services, home visiting, and other child and family services—all of which require a qualified and supported workforce.

In 2019, the Nevada Legislature enacted AB 430, requiring the Legislative Committee on Child Welfare and Juvenile Justice to conduct a study concerning maternal, infant and early childhood home visitation services. In 2019, Oregon enacted SB 526 to direct the Oregon Health Authority to design, implement and maintain a voluntary statewide program to provide universal newborn nurse home visiting services to all families within the state to support healthy child development and strengthen families.

New Hampshire passed SB 592 in 2018, which authorized the use of TANF funds to expand home visiting and child care services through family resource centers. A year later, New Hampshire passed SB 274 to allow all Medicaid-eligible children and pregnant women access to home visiting programs for children and their families.

Utah passed the Nurse Home Visiting Pay-for-Success Program (SB 161) in 2018 to create an evidence-based nurse home visiting pay-for-success program. The enacted legislation allows a contractual relationship between the Department of Health and one or more private investors. Success payments are provided to investors if the program meets the performance goals outlined in the pay-for-success contract.

In 2016, Rhode Island lawmakers passed the Rhode Island Home Visiting Act (HB 7034), which requires Rhode Island’s Department of Health to coordinate the system of early childhood home visiting services; implement a statewide home visiting system that uses evidence-based models proven to improve child and family outcomes; and implement a system to identify and refer families before the child is born or as early after the birth of a child as possible.

In 2013, Texas lawmakers passed the Voluntary Home Visiting Program (SB 426) for pregnant women and families with children younger than 6. Also in 2013, the Texas Legislature increased funding for at-risk prevention programs for child abuse and neglect prevention leading to the Healthy Outcomes Through Prevention and Early Support (HOPES) program, which began providing services the following year. The bill also established the definitions of and funding for evidence-based and promising practice programs (75% and 25%, respectively). Texas has a history of investing in home visiting dating back to 2007 with SB 156, which required the Health and Human Services Commission to establish a nurse-family partnership competitive grant program to serve approximately 2,000 families in multiple communities throughout the state.

In 2013, Arkansas lawmakers passed SB 491, requiring the state to implement statewide, voluntary home visiting services to promote prenatal care and healthy births. The bill required the state to use at least 90% of funding for evidence-based and promising practice models and to develop protocols for sharing and reporting program data and a uniform contract for providers.

Program standards provide a common understanding of how home visiting services should be delivered to achieve positive, measurable outcomes for infants and toddlers and their families.

Oklahoma’s Family Support and Accountability Act of 2015 requires performance outcomes to be measured and reported annually. New Mexico’s Home Visiting Accountability Act of 2013 established standards and reporting requirements for the home visiting programs receiving state funds. The act also requires that its Children Youth and Family Department create and disseminate an annual outcomes report.

Additional examples of legislative action are available through NCSL’s Early Care and Education Bill-Tracking Database, which contains introduced and enacted home visiting legislation for the 50 states, Washington, D.C., and the territories.

By the Numbers

• In 2017, more than 300,000 families received evidence-based home visiting services over the course of more than 3.5 million home visits. That same year the federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) grant program helped fund services for more than 81,000 families in states, territories and tribal communities.
• About 18 million pregnant women and families (including more than 23 million children) could benefit from home visiting but were not reached in 2017.
• In 2017, nine emerging models provided 406,182 home visits, serving 28,706 families and 28,798 children.
• In fiscal year 2018, MIECHV funding helped serve 150,000 parents and children.
• In fiscal year 2018, MIECHV funding supported more than 930,000 home visits.
• An additional 28,700 families received home visiting services through nine emerging models that do not yet meet the standards of evidence required by the Home Visiting Evidence of Effectiveness project. These nine models provided more than 400,000 home visits in 2017.

Hard-to-Reach Communities

According to the U.S. Census Bureau, 20% of the population lives in rural areas. Policymakers have considered increasing access to health care services through telehealth to reach patients in rural communities. Virtual tools are one way to expand the reach of home visiting services to hard-to-reach communities. Parents as Teachers at USC Telehealth, for example, is successfully providing home visiting services from a distance. There are limitations to this approach, however, as home visitors often model nurturing interactions with babies and children and physically demonstrate safe sleep practices.

Home Visiting Implementation, Workforce and Delivery

Sources of Funding

States rely on a mix of state and federal funds to support home visiting programs, and legislators face difficult decisions and competing priorities when determining how best to allocate limited funds. As reported in NCSL’s annual survey of early care and education budget actions, states also use general funds, tobacco settlement funds, tobacco taxes and private-sector funds to pay for home visiting. NCSL’s Early Care and Education State Budget Actions report for fiscal year 2019 shows that, of the 33 states that responded, three states reported a decrease in federal MIECHV funding and nine increased state general fund dollars from the previous year.

MIECHV is the primary source of federal funding for home visiting. It began in 2010 under the Affordable Care Act and was reauthorized in 2015 under the Medicare Access and the Children’s Health Insurance Program (CHIP) Reauthorization Act. In February 2018, it was reauthorized for another five years.

Since 2010, Congress has invested billions of dollars through MIECHV to help states, territories and tribes expand and implement evidence-based home visiting. Current funding provides $400 million per year through federal fiscal year 2022. Funds can be used for evidence-based programs, innovation, statewide needs assessments, training and technical assistance and evaluation. Some states, including Texas, use MIECHV funds to support community collaborations working on the systemic issues that influence family health and well-being.

The MIECHV program requires that 75% of federal funding be spent on evidence-based home visiting models, meaning programs have been verified as having a strong research basis. To date, 18 models have met this standard. The remaining 25% of funds can be used to implement and rigorously evaluate models considered to be promising or innovative approaches. These evaluations will add to the research base for effective home visiting programs.

In addition, the MIECVH program includes an accountability component requiring states to achieve certain benchmarks and outcomes. States must show improvement in the following areas: maternal and newborn health, childhood injury or maltreatment and reduced emergency room visits, school readiness and achievement, crime or domestic violence, and coordination with community resources and support. Programs are evaluated at the state and federal levels to ensure they are operating effectively and achieving intended outcomes.

Other sources of federal funds are available to support home visiting, including Title V of the Maternal and Child Health Block Grant Program, TANF, Project LAUNCH, Medicaid, Healthy Start, Early Head Start, the Child Abuse Prevention and Treatment Act and the Community-Based Child Abuse Prevention Program. Many states combine these resources. For example, Louisiana combines MIECHV funding, state general funds, federal maternal and child health dollars, Medicaid dollars, and TANF funding to support implementation of the Nurse-Family Partnership model. As of 2018, at least 20 states are using Medicaid financing for home visiting.

Items for Policymakers to Consider

Plan and coordinate with state agencies.

• Work in partnership with relevant state agencies when considering new or amended legislation.
• Ask about the supply and competencies of home visitors in your state and consider what actions may be necessary to build a supported and qualified workforce.
• Ask agency leadership or a legislative fiscal analyst to summarize state appropriations and the number of families served by home visiting programs in your state.
• Ask how your state is using data to inform decision making and continuous quality improvement.
• Dig into state-level data available through agency leaders and the Home Visiting Yearbook.
• Exercise caution when writing specific home visiting models into legislation.
• Prioritize desired outcomes and ask agency leaders to identify program model(s) that most closely align with the outcomes you have in mind.
• Home visiting is one component of your state’s early childhood system. Explore how it fits with other pieces, such as child care, early intervention and prekindergarten.
• Work with relevant agency staff to develop accountability measures and indicators of progress.

Build knowledge and connections.

• At least eight states have legislative children’s caucuses. If you live in one of those states, consider getting involved. If your state does not have a legislative children’s caucus, consider forming one.
• Experience at least one home visit firsthand. If possible, observe different models to better understand the nuances within the field of home visiting.
• Find examples of legislative action through NCSL’s Early Care and Education Bill-Tracking Database, which contains introduced and enacted home visiting legislation for the states, Washington, D.C., and territories.
• Forty-five states and the District of Columbia have an active Early Childhood Advisory Council. Attend a meeting or ask to meet with members of the council.

Be patient.

• Set a realistic time frame for program implementation and data collection, keeping in mind that data collection and analysis could take years to produce meaningful insights.
• Stay the course: Short-term funding commitments will not have a measurable impact on child and family outcomes.

Conclusion

The news of a pregnancy and the birth of a child can be blissful—and overwhelming. Early childhood home visitors are trained to help families during this time of transition. Through voluntary home visiting programs, parents and caregivers receive support, connect to community services and gain the skills they—and their children—need to thrive.

Many home visiting models are backed by evidence of effectiveness in meeting one or more objectives, such as increasing school readiness, preventing child maltreatment and promoting positive parenting and healthy child development. At the same time, local circumstances, such as availability of qualified home visitors, language and cultural differences and population density, can affect program outcomes. While not a silver bullet, home visiting is increasingly recognized by state, federal and local leaders across the political spectrum as an appropriate and effective option for improving child and family outcomes.