Home Visitation for Families with
Young Children
Emilie Stoltzfus
Specialist in Social Policy
Karen E. Lynch
Analyst in Social Policy
October 23, 2009
Congressional Research Service
7-5700
www.crs.gov
R40705
CRS Report for Congress
P
repared for Members and Committees of Congress
Home Visitation for Families with Young Children
Summary
Home visiting is a strategy for delivering support and services to families or individuals in their
homes. This report deals exclusively with home visiting as a service strategy for families with
young children or those expecting children. There are a variety of early childhood home visitation
models. These models typically seek to positively impact one or more outcomes across three
main domains: maternal and child health; early childhood social, emotional, and cognitive
development; and family/parent functioning. Depending on the particular model of early home
visitation being used, the visitors may be specially trained nurses, other professionals, or
paraprofessionals. Visits, which often occur weekly, may begin during a woman’s pregnancy or
some time after the birth of a child and may continue until the child reaches his/her second
birthday (in some cases) or enters kindergarten. Participation of families is voluntary.
Early childhood home visitation programs are in operation in all 50 states and the District of
Columbia. The current combined public and private annual investment in these services has been
estimated at between $750 million and $1 billion. This funding supports services for an estimated
400,000-500,000 families, or about 3% of all families (17.4 million) with children under six years
of age. In addition to private and state and local public funds provided for early childhood home
visitation, a number of federal programs have been tapped to support home visitation programs.
Among others, these include Medicaid, the Temporary Assistance for Needy Families block grant,
the Social Services Block Grant, the Promoting Safe and Stable Families program, Community-
Based Grants to Prevent Child Abuse and Neglect, Even Start, Part C early intervention services
for infants under the Individuals with Disabilities Education Act, the Maternal and Child Health
Block Grant, Healthy Start, and Early Head Start.
The current popularity of early childhood home visitation draws, in some measure, from newer
research on how the human brain develops and, specifically, the significance of prenatal and early
childhood environments to later life outcomes. Further, since at least the 1960s, a variety of home
visiting programs have undergone evaluations to test their effectiveness. While the results have
been mixed, some research has shown results that promise both immediate and longer term
benefits to children and their families, including improvements in birth outcomes, enhanced child
cognitive development and academic success, and strengthened child-parent interactions. Overall,
researchers caution that home visiting is not a panacea, but many have encouraged its use as part
of a range of strategies intended to enhance and improve early childhood.
Federal and congressional interest in early childhood home visitation is reflected in a number of
recent or current proposals. These include a proposal in the Administration’s FY2010 budget that
proposes mandatory funding for grants to states to support the establishment and expansion of
home visitation programs with strong evidence of effectiveness, as well as for programs showing
promise of efficacy. The FY2010 Budget Resolution (S.Con.Res. 13) anticipates possible
consideration of home visitation legislation (provided it is “deficit neutral”). Although the details
differ somewhat, health care reform bills pending in both the House (H.R. 3200) and Senate (S.
1796) would appropriate funds to provide grants to states for early childhood home visitation
programs. The House health care reform legislation would additionally clarify states’ ability to
claim federal Medicaid reimbursement for nurse home visiting services. Finally, several other
bills have been introduced in this Congress that would authorize or provide funds to states for
early childhood home visitation programs (including S. 244, H.R. 2205, H.R. 2667, and S. 1267).
This report will be updated as warranted.
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Home Visitation for Families with Young Children
Contents
Introduction ................................................................................................................................ 1
Current Practices and Initiatives in Home Visiting....................................................................... 2
Review of Selected Home Visiting Models............................................................................ 2
Target Population ............................................................................................................ 2
Age of Child When Service Begins and Ends .................................................................. 3
Length of Home Visits .................................................................................................... 3
Staff Qualifications and Training..................................................................................... 3
Goals .............................................................................................................................. 4
Implementation of Home Visiting by States......................................................................... 12
Current ACF Home Visitation Initiative............................................................................... 13
Existing Federal, State, and Local Funding Streams for Home Visiting...................................... 15
Federal Funding Sources ..................................................................................................... 15
State and Local Funding Sources......................................................................................... 18
Funding Sources by Home Visiting Model .......................................................................... 19
Current Investment In and Estimated Costs of Home Visiting.............................................. 21
Research and Evaluation of Existing Home Visiting Programs .................................................. 22
Methods for Evaluating Program Models ............................................................................ 23
Research Findings by Desired Program Outcomes............................................................... 24
Findings in the Maternal and Child Health Domain ....................................................... 25
Findings in the Child Social, Emotional, and Cognitive Development Domain .............. 30
Findings in the Family/Parent Functioning Domain ....................................................... 33
Recent Administration and Congressional Proposals to Support Home Visiting ......................... 36
Obama Administration’s FY2010 Budget Proposal.............................................................. 36
FY2010 Budget Resolution ................................................................................................. 38
Proposed Grants to States for Home Visitation in Health Care Legislation ........................... 38
Proposed Nurse Home Visitation Services Under Medicaid ................................................. 44
Hearing on Proposals to Support Early Childhood Home Visitation ..................................... 44
Tables
Table 1. Overview of Six Home Visiting Models ......................................................................... 5
Table 2. Number of Home Visiting Sites, by Selected Program Model and State ........................ 10
Table 3. Selection of Federal Funding Streams by Administering Agency and How
Program Funds May Be Used to Support Early Childhood Home Visiting .............................. 17
Appendixes
Appendix A. Selected Federal Programs That Provide or Support Home Visitation.................... 46
Appendix B. Federal Initiatives Related to Coordination of Early Childhood Programs
and Services........................................................................................................................... 52
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Home Visitation for Families with Young Children
Contacts
Author Contact Information ...................................................................................................... 55
Acknowledgments .................................................................................................................... 55
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Home Visitation for Families with Young Children
Introduction
Home visiting is a strategy for delivering support and services to families or individuals in their
homes. While home visiting may also be used to address needs of the chronically ill or elderly,
this report deals exclusively with home visiting as a service strategy for families with young
children or those who are expecting children. Further, as used in this report, the terms “home
visitation” or “home visiting programs” refer to structured models of interaction with families and
children; these programs have specific child and family goals, involve regular home visits over a
sustained period of time, and have established components or curricula to be covered during those
visits. Further, this kind of home visitation is typically implemented as a primary prevention
strategy—home visiting is offered before any specific “problem” (e.g., abuse or neglect of
children, early childhood developmental delays) has been identified. At the same time, many
home visitation models discussed in this report target services to families with certain risk factors
(e.g., low income, low social support) for poor child outcomes. In addition, some home visiting
programs implement intervention strategies meant to prevent recurrence of a poor outcome or to
limit any ongoing negative consequences.
There are a variety of early home visiting models. These models typically seek to positively
impact one or more child or family outcomes across three main domains: maternal and child
health; early childhood social, emotional, and cognitive development; and family/parent
functioning. Some estimates suggest that, at any point in time, as many as 400,000 to 500,000
families may be receiving early childhood home visitation services.1 This equals about 3% of all
families with children under the age of six (17.4 million families), or a little more than 7% of
those same families with income below 200% of the poverty line (7.0 million families).2
Depending on the particular model of early childhood home visitation being used, the visitors
may be specially trained nurses, other professionals, or paraprofessionals; visits may begin during
a woman’s pregnancy or later; and the visits may continue, regularly, until the child reaches
his/her second birthday or enters school. Participation of families is voluntary.
Early childhood home visitation is currently undergoing a phase of broad popularity. This appears
to be driven in some part by newer research on how the human brain develops and, specifically,
the significance of the prenatal and early childhood environments to later life.3 To a large extent,
parents shape their children’s earliest experiences, and because most home visiting programs seek
to help parents understand their own child’s development, advocates see these programs as an
opportunity to enhance child development, thereby achieving long-term positive benefits for the
children, their parents, and society. Further, at least since the 1960s, a variety of early childhood
home visiting models have undergone many assessments and evaluations intended to test how
effectively they achieve their goals. While the results of these evaluations have been mixed, some
models, or aspects of models, have been shown to be particularly effective. Overall, while
1 Deanna Gomby, Home Visitation in 2005: Outcomes for Children and Parents, Committee for Economic
Development, Invest in Kids Working Paper No. 7, 2005, p. 1 (hereinafter Gomby, Home Visitation in 2005). Deborah
Daro, Chapin Hall Center for Children and Families, Testimony before House Ways and Means Committee,
Subcommittee on Income Security, June 9, 2009.
2 U.S. Census Bureau, Population Division, Current Population Survey, 2008, Annual Social and Economic
Supplement, POV08 “Families with Related Children Under 6 by Number of Working Family Members and Family
Structure: 2007.” See http://www.census.gov/hhes/www/macro/032008/pov/new08_000.htm.
3 From Neurons to Neighborhoods: The Science of Early Childhood Development, ed. Jack P. Shonkoff, Deborah A.
Phillips (Washington, DC: National Academy Press, 2000).
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researchers have cautioned that home visiting is not a panacea, they have generally encouraged its
use as part of a range of strategies intended to enhance and improve early childhood.
Current Practices and Initiatives in Home Visiting
There are many “models” used to provide voluntary prenatal and early childhood home visitation.
At the state and community level, implementation of early childhood home visitation models can
vary greatly. Some states and communities rely on established models, others blend components
from more than one model, and some develop their own models. In addition, many states support
more than one model of home visiting. These models may target different groups of families,
have different primary goals, and/or operate in different parts of the state.
The Administration for Children and Families (ACF), an agency of the U.S. Department of
Health and Human Services (HHS), is currently carrying out a competitive grant initiative
intended to assist grantees in implementing home visitation models that have been proven
effective. Apart from this research initiative (described below), the federal government currently
supports some ongoing programs in which home visitation is a primary strategy for achieving
program goals (e.g., Early Head Start), others in which support for home visiting is explicitly
permitted or strongly suggested by the program’s statutory authority (e.g., Maternal and Child
Health Block Grant and Promoting Safe and Stable Families), and still others where the broad
purposes of the program allow use of funds for some or all of the activities supported by home
visitation programs (e.g., Temporary Assistance for Needy Families (TANF), Medicaid).
Review of Selected Home Visiting Models
Home visiting models can be differentiated by, among other things, who they intend to serve, the
intensity and duration of services, staff qualifications and training, specific program goals, and
the exact services or curricula they use in working with families. Some program characteristics of
six early childhood home visitation models—Healthy Families America, Parents as Teachers,
Nurse-Family Partnership, Home Instruction for Parents of Preschool Youngsters, the Parent-
Child Home Program, and SafeCare—are discussed below as examples of early childhood home
visitation programs. Each of these home visitation models was privately originated, has
established core program components and specific training standards, and has been evaluated
with results published in peer-reviewed journals. Further, each of these models has available
materials and other resources that may be used to replicate the model. Readers should be aware,
however, that there are other models in existence that meet some or all of the criteria discussed
above (e.g., Maternal and Infant Health Outreach Worker4). Therefore, the discussion of these
models is meant to be illustrative rather than exhaustive.
Target Population
Early childhood home visitation is typically understood as a primary prevention strategy rather
than an intervention strategy. Accordingly, in most of the home visiting models reviewed here
services are made available to families before any “problem” has been identified. For example,
4 The MIHOW program is associated with the Vanderbilt University Medical Center and has been implemented at 20
sites in five states. For more information see http://www.mihow.org/overview.html.
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Home Visitation for Families with Young Children
services are typically available before a family is reported as having abused or neglected a child,
or before any particular developmental delay is found in a child. At the same time, some models
target families with specific demographic features that suggest additional family support may be
needed or useful. The Nurse Family Partnership model focuses exclusively on low-income, first
time mothers who are identified during their pregnancy. The Healthy Families model typically
targets a broader set of families, including pregnant women or families with pre-school age
children who are identified as “at-risk” using a standardized assessment tool. However, individual
sites where the Healthy Families model is being implemented may choose to serve only particular
subgroups within that broader target population. By contrast, the Parents as Teachers model
espouses a principle of universal access for families with young children (including pregnant
women). Finally, the SafeCare model is more narrowly focused, and is primarily directed at
families where a report of child abuse or neglect has been made. Thus while it intends to prevent
additional maltreatment, it is specifically designed to intervene in families where a problem
(report of child abuse or neglect) has already been identified.
Age of Child When Service Begins and Ends
As noted above, several models are being used to provide home visitation programs to pregnant
women or to families with young children. These programs may continue for the length of time it
takes to cover a specific model’s curriculum or they may continue until the child reaches a certain
age. For example, both the Healthy Families America and the Parents as Teachers models may
begin visitation during pregnancy or after birth of a child and generally continue until the child is
enrolled in kindergarten. By contrast, the Home Instruction for Parents of Preschool Youngsters
(HIPPY) and Parent-Child Home Program models do not begin until a child is approximately 2 or
three years of age, but also typically end around the time of the child’s enrollment in preschool or
kindergarten. Separately, the Nurse Family Partnership model requires that services begin during
the first-time mother’s pregnancy and end with the child’s second birthday. The SafeCare model
is implemented after the birth of a child and continues only for the length of time it takes to cover
the program curriculum (typically four or five months).
Length of Home Visits
Visits may occur weekly, biweekly, or on a monthly basis. In some models, visits may occur less
often as the family progresses through the program. Both the HIPPY and Parents as Teachers
models include group meetings (outside the home and with other families) as part of their
program model. Home visits typically last one hour, although some models include 30-minute
visits and others suggest that a single visit may continue for up to 90 minutes.
Staff Qualifications and Training
The Nurse Family Partnership program is the only model discussed here that requires a specific
education degree; home visitors in this model must be registered nurses. In all of the other
program models, individuals of any education level may become visitors provided they
successfully complete training under the program model. Home visitors in these models may have
bachelor’s or higher level education degrees, though this is not always required. The Healthy
Families model stresses the home visitor’s ability to establish rapport with families as critical.
Some program models (e.g., Parents as Teachers, HIPPY, Parent-Child Home Program) prefer
that home visitors be from the local community—or even that they be alumni of the home visiting
program—as a way to help establish credibility or a connection between home visitors and
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Home Visitation for Families with Young Children
families. Finally, the SafeCare model identifies willingness to implement a structured service
delivery protocol as a key criterion for its home visitors.
Goals
Primary goals also vary by program model, as do the kinds of activities used by each model to
achieve those goals. Some program models focus more heavily on the school-readiness aspect of
early childhood development (e.g., HIPPY, Parent-Child Home Program) while others are more
broadly focused on child development issues, as well as maternal and child health, and family
functioning. Across all program models, a variety of methods (some very structured, others less
so) are used to offer parents information about their child’s growth and development.
Table 1 outlines goals and other characteristics of the six home visiting program models
discussed above.
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Table 1. Overview of Six Home Visiting Models
Program Model,
Target Population,
Service Onset
and Annual Cost
and Duration
Staff and Training
Goals
Services / Curricula
Healthy Families America During pregnancy or Ability of visitor to connect
Prevent child abuse and
Healthy Families America visitors will (1) ensure that families have
(HFA)
within two weeks of with family is of primary
neglect;
a medical provider; (2) share information on child development
child’s birth through
importance. Visitors may,
processes and work with parents on caring for children as babies,
Families with preschool child’s enrollment in but are not required to,
Enhance child health and toddlers, and beyond; (3) help parents to recognize the child’s
age children or
either preschool
have bachelor’s degree in
development; and
needs and to obtain appropriate resources; (4) assist families in
pregnant women
(age three or four)
social work, education, or
following through with recommended immunization schedules; (5)
identified as “at risk”
Promote positive
or kindergarten (age nursing.
help families to feel empowered; and (6) link families with
using a standardized
parenting.
five).
community resources for additional services (e.g., job placement,
assessment tool (sites
Home visitors receive four
child care providers, financial services, food and housing assistance
may choose particular
For the first six
days of “primary” training
programs, family support centers, substance abuse treatment
target populations
months, visits are
on supporting healthy child
programs, domestic violence shelters, etc.).
within this group).
intended to be
development, positive
weekly, after which
parent-child relationships,
Services focus on supporting the parent as wel as supporting
$3,348 per family on
visits are intended
improved parental
parent-child interaction and child development.
average
to occur twice each
problem-solving skills, and
month.
family support systems.
Visitors also receive about
80 hours of wraparound
training (e.g., local
chal enges and resources)
during their first six months
on the job.
Nurse Family Partnership Home visits during
Registered nurses.
Improve pregnancy
Prior to the birth of the child, NFP home visitors seek to improve
(NFP)
pregnancy through
outcomes;
pregnancy outcomes by addressing (1) effects of smoking, alcohol,
child’s second
Nurses receive over 60
and drugs (including identifying plans to decrease usage, as
Low-income, first-time
birthday.
hours of instruction from
Improve child health and necessary); (2) best practices in nutrition and exercise for pregnant
mothers (including
the NFP Professional
development; and
women (including monitoring for adequate weight gain and other
pregnant women)
Ideally, home visits
Development Team over a
risk factors); (3) preparation for childbirth and basics of newborn
begin in the 16
Improve economic self-
th
period of 12 to 16 months.
$2,914-$6,463 per
care; (4) adequate use of office based prenatal care; (5) referrals to
week of pregnancy.
sufficiency of the family.
family on average
other health and human services as needed.
Over the course of
After the child’s birth, nurses work with families to improve the
about 2.5 years,
child’s health and development. To this end, nurse home visitors
visitors plan to
(1) conduct parent education on infant/toddler nutrition, health,
conduct around 64
growth and development, and environmental safety; (2) conduct
visits of 60-90
role model activities to promote sensitive parent-child interactions
minutes each.
to enhance child’s development; (3) use specific assessment tools
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Home Visitation for Families with Young Children
Program Model,
Target Population,
Service Onset
and Duration
Staff and Training
Goals
Services / Curricula
and Annual Cost
Visits occur weekly
to monitor parent-child interactions and infant/toddler
during the first
developmental progress at selected intervals, providing follow-up
month and in the
guidance to parents as needed; (4) provide guidance in cultivating
postpartum period.
social support networks and assessing safety of potential/actual
Visits later fade to
child care arrangements; (5) promote adequate use of
bimonthly (through
preventative/well-child care; and (6) continue to provide referrals
21 months) and then
to other health and human services as needed.
monthly.
Nurse home visitors also seek to improve the parent’s life-course
by working with parents on (1) realistic goal-setting exercises to
facilitate decision-making about the future, including strategies to
achieve education and work goals; (2) fostering relationships with
community services; and (3) issues related to family planning.
Parents as Teachers
During pregnancy
Home visitors, or “parent
Increase parent
PAT has four service delivery components: (1) home visits, (2)
(PAT)
through enrollment
educators,” are typical y
knowledge of early
group meetings, (3) screenings, and (4) resource networks.
in preschool (age
paraprofessionals (about
childhood development
All families with young
Home visits are the primary service delivery component. During
three) or
50% had a bachelor’s
and improve parenting
children (including
visits, parent educators share age-appropriate child development
kindergarten (age
degree in 2006-2007).
practices;
pregnant women)
information with parents, help parents learn to observe their
five).
These home visitors may
Detect developmental
child's development, address parenting concerns, and engage the
$1,400-$1,500 per
be parents who previously
Combination of 60-
delays and health issues
family in activities that provide meaningful parent/child interaction
family on average
received PAT services
minute home visits
and support the child's development.
themselves.
early;
(these may be
Group meetings are opportunities to discuss information about
monthly, biweekly,
Certification requires that
Prevent child abuse and
parenting issues and child development. Parents learn from and
or weekly) and
home visitors attend a five-
neglect; and
support each other, observe their children with other children,
group meetings.
day institute and a follow-
Increase children’s
and practice parenting skills.
up training within the first
school readiness and
year.
success.
Parent educators are required to conduct annual developmental,
health, vision, and hearing screenings for early identification of
Training covers sequences
developmental delays and other problems. Home visitors conduct
of early development,
screening themselves if they have received adequate required
screening techniques to
training. As an alternative, a program may have other trained
identify health or
personnel or agencies conduct the screenings. Regular review of
developmental issues, and
each child’s developmental progress identifies strengths as well as
facilitation of parent-child
areas of concern that may require referral for fol ow-up services.
interaction.
Parent educators also help families to connect with needed
resources and overcome barriers to accessing services. PAT
programs establish ongoing collaborative relationships with
community agencies and organizations that offer helpful family
services.
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Home Visitation for Families with Young Children
Program Model,
Target Population,
Service Onset
and Duration
Staff and Training
Goals
Services / Curricula
and Annual Cost
Home Instruction for
Children ages three
Home visitors are
Promote school
HIPPY has a proscriptive curriculum containing 30 weekly activity
Parents of Preschool
to five years old.
paraprofessionals (most
readiness and early
packets, nine storybooks and a set of 20 manipulative shapes for
Youngsters (HIPPY)
have a high school diploma
literacy through parental each year. During each visit, the home visitor provides the parent
Blend of 30 minute
or equivalent). Home
involvement.
with the tools and materials that enable parents to work directly
Typically low-income
biweekly home visits visitors are members of the
with their children on developmentally appropriate, skill building
families with little
and two hour
community and are usual y
activities.
education
biweekly group
current or former
meetings over the
Role play is the primary method of instruction used by the HIPPY
$1,250 per child on
recipients of HIPPY
course of three
curriculum—coordinators role play with home visitors, home
average
services.
years.
visitors role play with parents, and parents then implement
Home visitors are not
activities directly with their children.
encouraged to serve in that
capacity for more than
The HIPPY curriculum is primarily cognitive-based, focusing on
three years.
language development, problem solving, logical thinking, and
perceptual skills. Learning and play mingle throughout the HIPPY
Coordinators and visitors
curriculum as parents expose their children to early literacy skills
receive intensive pre-
such as (1) phonological and phonemic awareness, (2) letter
service training.
recognition, (3) book knowledge, and (4) early writing experiences.
The HIPPY curriculum emphasizes early reading and writing skills,
Coordinators provide
as well as skill building activities through singing, rhyming, puzzles,
weekly and periodic in-
etc.
service training to increase
the knowledge, confidence,
Group meetings are two hours long and are intended to bring
and effectiveness of the
parents together to share their experiences. During the first hour,
home visitors.
parents discuss the previous week’s activity and role play the
subsequent week’s activity. In the second hour, parents engage in
enrichment activities, which may cover issues related to parenting,
employment, school/community/social services, and personal
growth. The topics and objectives for the enrichment activities are
selected by parents. Child care is provided during the group
meeting—many programs also include Parent and Child Time
(PACT) as a component of group meetings, allowing parents to
observe and practice alternative methods of child rearing.
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Home Visitation for Families with Young Children
Program Model,
Target Population,
Service Onset
and Duration
Staff and Training
Goals
Services / Curricula
and Annual Cost
Parent-Child Home
Most children
Home visitors are typical y
Prepare young children
The PCHP curriculum espouses modeling behavior (rather than
Program (PCHP)
participate while
paraprofessionals. Visitors
for school readiness by:
teaching) as the most effective, non-intimidating way to empower
two to three years
are not required to have
parents and strengthen the quality of parent-child interactions.
Typically low-income
old. (Services may
bachelor’s degree in social
Increasing language and
families with little
go to a child as
work, education, or
literacy skills;
On the first visit of each week, PCHP home visitors bring a
education and multiple
young as 16 months
nursing, but some do. Some
carefully selected book or educational toy as a gift to the family.
risk factors
Enhancing social-
or as old as four
are also former recipients
Over the course of two years in the program, families acquire a
emotional development; library of children’s books and a collection of educational and
$2,187 per family on
years.)
of PCHP services (about
and
stimulating toys. Among other things, books and toys are used to
average
one-third per a 2003
30-minute home
study).
Strengthening the
(1) stimulate verbal interaction, (2) expand vocabulary, (3)
visits twice a week
parent-child
reinforce phonemic awareness, and (4) promote problem solving
over two program
They receive training in
relationship.
and reasoning.
years.
multicultural awareness and
the ethics of home visiting.
During visits with parents and children, the home visitor models
A “program year”
Visitors model, rather than
verbal interaction, reading, and play activities, demonstrating how
consists of a
teach, behaviors to parents.
to use the books and toys to cultivate language and literacy skills
minimum of 23
Visitors provide families
to promote school readiness. These activities are careful y
weeks of home visits with developmentally
designed to enhance the child’s cognitive and social-emotional
(or 46 home visits).
appropriate books and
development.
toys.
SafeCare
Birth to five years
There are no educational
Teach parents skills that
The SafeCare parent-training curriculum includes three modules
requirements. Trainees
enable them to:
that are taught sequential y. The home visitor uses a seven step
Parents who are at-risk One- to two-hour
must be motivated to
format, which is based on social learning theory. The steps are (1)
or have been reported
visits per week for
implement SafeCare, open
Recognize symptoms of
describe desired target behaviors; (2) explain rationale or reason
for child abuse or
18-20 weeks.
to new services models,
illnesses and injuries and for each behavior; (3) model each behavior; (4) ask parents to
neglect.
and interested in using a
seek the most
practice the behavior; (5) point out positive aspects of parent’s
appropriate health
$2,275 per family on
structured protocol for
performance; (6) point out aspects of parent’s performance
treatment;
average (program
service delivery.
needing improvement; (7) review parents’ performance and have
estimate based on
them practice areas needing improvement and set goals for the
Trainings is conducted with
Identify and reduce
statewide
next week. Each module is typically covered in six visits (one for
low trainee to trainer ratios environmental and
implementation in
assessment and five for training) but trainers work with parents
of 1:3 or 1:4. and is based
health hazards in the
Oklahoma)
until they meet the set of skill based criteria established for each
on the same principles of
home;
module. Throughout these modules, the home visitor is also
behavioral skill acquisition
Engage in positive
expected to do problem solving, with parents, as necessary.
used in the SafeCare
parent-child/
program for parents.
parent-infant
Health module: In the first module parents learn to use reference
materials to prevent illness, identify symptoms of childhood
Training begins with a five-
interactions and prevent illnesses or injuries, and provide or seek appropriate treatment.
day workshop focused on
child behavior problems. Parents are given a medically validated health manual, health
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Home Visitation for Families with Young Children
Program Model,
Target Population,
Service Onset
and Duration
Staff and Training
Goals
Services / Curricula
and Annual Cost
the three SafeCare modules
recording charts, and basic health supplies (e.g., thermometer).
and on problem solving and
communication. In addition
Home safety module: In the second module the focus is on helping
to lectures and viewing
parents identify and eliminate safety and health hazards by making
videos of sample home
them inaccessible to children. A standardized checklist is used.
visits, trainees watch
Safety latches are supplied to families.
modeling of skills by the
Parent-infant (birth to 8-10 months)/parent-child (8-10 months to
trainer, participate in role-
five years) interaction module: In this module parents are taught
play exercises, and receive
how to provide engaging and stimulating activities with their
feedback from the trainer.
children. The visitor observes parent-child play and/or daily
They are provisionally
routines and provides feedback to reinforce positive behavior and
certified after completing
address problem behavior. Parents are taught to use a Planned
the workshop and then
Activities Training checklist to help structure everyday activities.
receive field
Parents also receive activity cards with prompts for engaging in
implementation feedback
planned activities.
from a SafeCare coach.
They receive full SafeCare
Structured problem-solving and counseling: Structured problem
certification after mastering
solving is used by home visitors to help parents work through
skills. Additional training is
issues not addressed in the curriculum. This involves framing the
required for SafeCare
problem, identifying possible solutions, identifying pros and cons of
coaches and trainers.
each solution, choosing a solution, and acting.
Source: Prepared by the Congressional Research Service based primarily on information provided at program model websites.
CRS-9
Home Visitation for Families with Young Children
Table 2 shows the presence of five of these program models by state, including the number of
locations in which the model operates within the state. Please note that the number of sites for a
given model are not necessarily comparable because they may be of very different sizes (both
geographically and in terms of the number of families served). Data shown are based on
information provided on the websites of the given program. State-by-state information was not
available on the program website for SafeCare. (However, the SafeCare website does indicate that
the model has been implemented statewide in Oklahoma, is undergoing statewide implementation
in Georgia, and has also been implemented in one or more locations in California, Washington,
and Maryland.)
Table 2. Number of Home Visiting Sites, by Selected Program Model and State
State
Healthy Families
Parents as
Parent-Child
Americaa
Teachersb
HIPPYc
Nurse Family
Partnershipd
Home Programe
Alabama 2
21
12
1
0
Alaska
5 19 0
0 0
Arizona
14 34 1
1 0
Arkansas 1
14
45
0
0
California
2 120 7
10 7
Colorado
0 37 6
18 0
Connecticut 8 107 0
0 1
Delaware
0
4 0
0 0
District
of
Columbia
1
1 2
0 1
Florida 39
37
19
1
2
Georgia
14 49 0
0 0
Hawai
9
2 5
0 0
Idaho
0 33 0
0 0
Illinois 36
197 2
2 2
Indiana
56 61 0
0 1
Iowa
14 73 0
0 0
Kansas
5 223 1
0 0
Kentucky
4 41 1
1 0
Louisiana
2
7 7
16 0
Maine
9 17 0
0 0
Maryland
15 48 5
1 0
Massachusetts 33
5 0
0 34
Michigan
10 99 1
5 2
Minnesota
3
9 1
5 1
Mississippi
0 33 0
0 0
Missouri
1 559 0
3 0
Montana
0 14 0
0 0
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Home Visitation for Families with Young Children
Healthy Families
Parents as
Nurse Family
Parent-Child
State
Americaa
Teachersb
HIPPYc
Partnershipd
Home Programe
Nebraska
0 16 0
0 0
Nevada
0
9 2
1 0
New
Hampshire
0 22 0
0 0
New
Jersey 18 26 1
7 2
New
Mexico 1 42 0
0 0
New York
28
49
4
7
32
North
Carolina 9 86 0
7 1
North
Dakota 1 18 0
1 0
Ohio
9 71 3
4 1f
Oklahoma
7 103 1
1 0
Oregon
15 47 2
1 0
Pennsylvania 4 90
0
23
28
Rhode
Island 0 20 1
0 0
South Carolina
5
89
0
6
22
South
Dakota 0 22 0
2 0
Tennessee
4
8 1
0 0
Texas 6
87
14
11
0
Utah
0 18 0
1 0
Vermont
0
2 0
0 0
Virginia
33 32 1
0 0
Washington 0 26 0
10 6
West
Virginia 2 15 0
0 0
Wisconsin
5 37 1
1 0
Wyoming
0 14 0
14 0
Total
program
sites
430 2,813 146
161 143
Source: Prepared by the Congressional Research Service (CRS), based on sources outlined below.
Note: The numbers of sites for a given model are not necessarily comparable because they may be of very
different sizes (both geographical y and in terms of number of families served).
a. 2003 Annual Profile of Program Sites dated December 2004, available on HFA website (as of April 9, 2009),
http://www.healthyfamiliesamerica.org/downloads/hfa_site_survey.pdf.
b. Document at PAT website, dated August 2007. No “Meld” or “Meld affiliate” sites shown.
c. Information at HIPPY website (as of April 9, 2009), http://www.hippyusa.org/site/view/
StateOfficesContactswithMap.pml.
d. Information at NFP website (as of April 9, 2009), http://www.nursefamilypartnership.org/content/index.cfm?
fuseaction=showMap&navID=17.
e. Information at PCHP website (as of April 9, 2009), http://www.parent-child.org/localsites/index.html.
f.
Ohio is listed as a PCHP state, but no information was provided about the number of participating sites. For
the purposes of this table, CRS assumes a minimum of one site operating within the state.
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Implementation of Home Visiting by States
Currently many states and localities have implemented home visiting programs as part of a range
of family support and/or early childhood interventions or services. Among 46 states that
responded to a 2007 survey conducted by Columbia University’s National Center on Children in
Poverty (NCCP), 40 indicated the presence of one or more “state-based” home visiting
programs.5 The survey defined “state-based” to include any distinct program model that was
administered by the state (in most instances) or otherwise coordinated by state agencies
(excluding Early Head Start, Healthy Start, and the Infants and Toddlers Program funded under
Part C of the Individuals with Disabilities Education Act).6 The survey separately noted that in 24
states, at least 32 distinct programs operated under a state legislative mandate or with some state-
legislated program content.
The NCCP survey indicated that most publicly funded home visiting programs targeted low
income families with certain risk factors.7 Further, the survey showed that the most commonly
identified program goals for state-based home visiting programs were related to parenting and
children’s early health and development. Around 70% of the state-based programs included in the
2007 survey identified program goals in those categories. Just above half of all programs
identified outcomes related to pregnancy (e.g., increased time interval between pregnancies).
Reduction of government services related to child abuse was cited as a program goal in a little
more than 40% of the programs.8
As used in the NCCP survey, a single state-based “program” refers to a particular home visiting
model that might be in operation at one or many sites in the state. Many of the states responding
to the survey had more than one distinct “state-based” home visiting program in place. Further,
the survey showed that while some of those programs were based on well-known home visiting
models, most were not.9 Of the 70 state-supported, administered, or coordinated programs
identified in 40 states, only 17 (identified by 14 states) were implementing one of the well-known
home visiting models, such as Healthy Families, Nurse Family Partnership, Home Instruction
Program for Preschool Youngsters (HIPPY), and Parents as Teachers. Separately, 14 of the state-
supported, administered, or coordinated programs (in 14 states) used more than one of those well-
known home visiting models or some combination of different elements from those models (e.g.,
a “blended design”).10 However, the majority (the remaining 39) of these state-funded,
administered, or coordinated programs reported using “homegrown” models.11 The use of
5 Kay Johnson, State-based Home Visiting: Strengthening Programs through State Leadership, National Center for
Children in Poverty, Mailman School of Public Health, Columbia University, February 2009 (hereinafter Johnson,
State-based Home Visiting Programs, 2009). The District of Columbia along with four states (Indiana, Kansas,
Vermont, and Washington) did not respond to this survey.
6 Six states are listed as reporting no state based programs: Alaska, California, Idaho, Mississippi, North Dakota, and
Nebraska. While the survey does not include California among those reporting “state based” programs, it is worth
noting that, according to the website of the Parent-Child Home Program, seven PCHP sites operating in California are
funded under California’s First 5 initiative.
7 Johnson, State-based Home Visiting, 2009, p. 5.
8 Kay Johnson, Results from a Survey of State-based Home Visiting Programs, National Center for Children in Poverty,
“Focus on Home Visiting” webinar, December 2, 2008, http://www.nccp.org/projects/events/event_43.html
(hereinafter, NCCP “Focus on Home Visiting” webinar, 2008).
9 Ibid.
10 Johnson, State-based Home Visiting, p. 11.
11 Kay Johnson remarks, NCCP “Focus on Home Visiting” webinar, 2008.
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blended or homegrown models may reflect efforts by states to address particular needs of a
specific target population, to vary intensity of service by identified family need, to offer the
amount of services they can financially support, and/or to provide a level of service that will be
locally accepted.12
In a 2006 report reflecting on implementation of home visiting programs in several states,
researcher Miriam Wasserman observed that in most locations there was not a deliberate effort to
identify a program with the most evidence of success. Typically, she writes, statewide
programs—of whatever model—were launched in one or more sites based on response to
specific, locally identified needs. This attracted the notice and interest of other sites in the state
(along with some entrenched local interests), which in turn led to more secure federal or state
funding, and ultimately to greater proliferation of that program model. Noting that grassroots
efforts have been critical, she also cites the importance of influential champions of a particular
model. These might be legislators or other state leaders. As examples, she cites the importance of
a 1991 early childhood initiative by then Indiana Governor Evan Bayh in the development of a
statewide Healthy Families network in that state; the efforts of Michele Ridge, wife of former
Pennsylvania Governor Tom Ridge, in the spread of Nurse Family Partnership in Pennsylvania;
support of then Arkansas first lady Hillary Clinton in spreading the HIPPY model in Arkansas;
and the arrival of the Parents as Teachers model in Idaho, which she credits to the relationship
between Senator “Kit” Bond of Missouri—where the Parents as Teachers model was first
demonstrated and then broadly replicated—and former Idaho Senator Dirk Kempthorne,13 who
subsequently became governor of that state.
Current ACF Home Visitation Initiative
Noting that states did not always follow “proven-effective” models of home visitation, the Bush
Administration requested additional funding in FY2008 to provide competitive grants to “expand,
upgrade, or build nurse home visitation programs.” The Bush Administration sought $10 million
(as a set aside within the discretionary activities account of the Child Abuse Prevention and
Treatment Act, CAPTA) for these grants to “support investments in quality assurance systems,
training, technical assistance, workforce recruitment and retention, evaluation, and other
administrative mechanisms needed to successfully implement and sustain high quality, evidence-
based home visitation programs that have strong fidelity to a proven effective model” and to
support a national cross-site evaluation to examine factors associated with successful replication
or expansion of “proven-effective models.”14 Congress supported the funding request, providing
$10 million in FY2008 appropriations (P.L. 110-161) to support “competitive grants to States to
encourage investment of existing funding streams into evidence-based home visitation models.”
Further, Congress stipulated that HHS must “ensure that States use the funds to support models
that have been shown, in well-designed randomized controlled trials, to produce sizeable,
sustained effects on important child outcomes such as abuse and neglect. Funds shall support
12 Miriam Wasserman, Implementation of Home Visitation Programs: Stories from the States, Chapin Hall Center for
Children, University of Chicago, Issue Brief No. 109, September 2006, p. 16 (hereinafter Wasserman, Implementation
of Home Visiting, 2006); and Johnson, State-based Home Visiting, 2009, p. 16.
13 Wasserman, Implementation of Home Visitation Programs, 2006.
14 U.S. Department of Health and Human Services, Administration for Children and Families, FY2008 Justification of
Estimates for Appropriations Committees, February 2007, pp. 115-116. The initial request also made several references
to the effectiveness of nurse home visitation and specifically to expanding “proven effective models of nurse home
visitation.”
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Home Visitation for Families with Young Children
activities to assist a range of home visitation programs to replicate the techniques that have met
these high evidentiary standards.”15 For FY2009, Congress directed that $13.5 million be set
aside to continue the home visitation initiative16 and the Obama Administration has requested
continued funding at that same level for FY2010.17
On September 30, 2008, the Administration for Children and Families (ACF) at HHS awarded
cooperative agreements to 17 grantees in 15 states to support “state and local infrastructure
needed for the high quality implementation of existing evidence-based home visiting programs to
prevent child maltreatment.” The grants are valued at $500,000 per year and, if appropriations are
continued, should be extended across a total of five years. These 17 grantees seek to implement or
enhance and study a variety of home visiting models (alone or in combination). These models
include the Nurse Family Partnership, Healthy Families America, Parents as Teachers, and
SafeCare models, as well as the Positive Parenting Program (Triple P) and a separate model
known as Family Connections. In addition to these cooperative agreements, HHS/ACF awarded
funds to Mathematica Policy Research, Inc., and the Chapin Hall Center for Children to conduct a
cross-site evaluation of the funded programs, to include study of model implementation, fidelity,
outcomes, and costs. Mathematica and Chapin Hall are also charged with providing technical
assistance to grantees and their local evaluators, and they must establish and coordinate a peer
learning network to allow grantees, federal staff, and other stakeholders to share information.18
Recipients of the cooperative agreement award were to spend the majority of the first year under
the agreement (i.e., most of FY2009) engaged in collaborative planning efforts and the remaining
expected four years (i.e., FY2010-FY2013) implementing that plan. Among other things, the
collaborative planning effort is meant to ensure that “all relevant programs and funding streams
are identified and included” in the coordination efforts. Ultimately, the plan is expected to lay out
the necessary infrastructure for widespread adoption, implementation, and continuation of
evidence-based home visiting programs and it will serve as a roadmap for the implementation
phase of the cooperative agreement.19
Because it is “very interested in interagency collaborative efforts across various disciplines,”
HHS/ACF (through its Children’s Bureau) has required that the planning and implementation
process for these home visitation projects must include the state or local child welfare agency and
the state’s designated lead agency for the Community-Based Child Abuse Prevention Program
(CBCAP, authorized under Title II of the Child Abuse Prevention and Treatment Act (CAPTA),
which is administered by the Administration for Children and Families of HHS).20 (For more
15 U.S. Congress, House Appropriations Committee Print, Division G, Explanatory Statement to accompany the
Consolidated Appropriations Act, 2008 (H.R. 2764), pp. 1540-1541.
16 See Congressional Record, February 23, 2009, H.R. 2228. The additional funding will be used to increase support
for the original grantees.
17 U.S. Department of Health and Human Services, Administration for Children and Families, FY2010 Justifications of
Estimates for Appropriations Committees, May 2008, p. 122 (hereinafter cited as HHS/ACF, FY2010 Justifications of
Estimates).
18 See ACF, Children’s Bureau, “Supporting Evidence-Based Home Visiting to Prevent Child Maltreatment,” no date,
http://www.acf.hhs.gov/programs/cb/programs_fund/discretionary/visitation/ebhv_project_description.pdf. For
FY2009, the maximum grant amount for the 17 grantees was increased above $500,000 and additional funding was
provided for the cross-site evaluation because of increased appropriations in that year.
19 ACF Grant Opportunities, Funding Opportunity HHS-2008-ACF-ACYF-CA-0130, Supporting Evidence-Based
Home Visitation Programs to Prevent Child Maltreatment (expired July 21, 2008).
20 CBCAP funding was $42 million for FY2009. The grants are distributed by formula to a lead entity in every state.
That entity, which may be public or a private non-profit, must use the fund to support community based activities to
(continued...)
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information on CBCAP, see “Selected Federal Programs That Provide or Support Home
Visitation,” Appendix A.) The Children’s Bureau also “strongly recommended” collaboration
with grantees under two other federally supported efforts related to improving outcomes for
young children. These are the State Maternal and Child Health Early Childhood Comprehensive
Systems (ECCS) grantees (competitive grants administered by the Health Resources and Services
Administration of HHS and currently funded in as many as 47 states)21 and Linking Actions for
Unmet Needs in Children’s Health (or “Project LAUNCH” competitive cooperative agreements,
now in place in seven locations and administered by the Substance Abuse and Mental Health
Services Administration of HHS). (For more information on these and other “Federal Initiatives
Related to Coordination of Early Childhood Programs and Services,” see Appendix B.) 22
Existing Federal, State, and Local Funding Streams
for Home Visiting23
Most home visiting programs now in operation use a blend of federal and state funding streams,
with some additional support coming from local public funds or private sources.24 For example,
support for Healthy Families America (HFA) programs in 2004 came from an average of 2.4
federal funding sources, 2.0 state funding sources, and 2.7 local funding sources by state.25
Federal Funding Sources
Current and/or past sources of federal funding for home visiting have come from programs
administered by several different federal agencies, most commonly the U.S. Department of
Health and Human Services (HHS) and the U.S. Department of Education (ED). Support from
existing federal programs comes in several different ways. Some programs, such as Early Head
Start, operate what amounts to their own home visiting model. For other programs, such as the
Maternal and Child Health Block Grant, home visiting services are explicitly permitted by statute,
but as one of a range of activities eligible to receive a share of program funding. Finally, there is a
larger pool of federal programs, including Medicaid and Temporary Assistance for Needy
Families (TANF), which may support early childhood home visitation under broadly stated
program authorities. In the latter case, the statute does not explicitly focus on home visiting;
(...continued)
prevent child abuse and neglect. Voluntary home visiting is described in the program statute as a “core service” and is
supported in many if not all states with a portion of these funds.
21 The FY2009 funding for Early Childhood Comprehensive Systems (ECCS) was $7 million. The ECCS seeks to
foster integrated efforts for the delivery of services to young children across health, human service, and education
agencies. For more information see http://www.state-eccs.org/componentareas/index.htm.
22 The FY2009 funding for Project LAUNCH was $20 million, up from $7.5 million in FY2008. For more information
see http://projectlaunch.promoteprevent.org/.
23 CRS sought to be thorough in compiling these data. However, information included on funding sources (particularly
at the state and local levels) may not be comprehensive.
24 For more information, see Johnson, State-based Home Visiting, 2009; Wasserman, Implementation of Home
Visitation, 2006; and Healthy Families America, “Chapter 8: Funding,” in State Systems Development Guide, 2003,
http://www.healthyfamiliesamerica.org/downloads/ssdg8.pdf.
25 Healthy Families America, State of State Systems in 2004: Funding Results from the 2004 State Systems Survey, May
17, 2004, PowerPoint at http://www.healthyfamiliesamerica.org/network_resources/hfa_state_of_state_systems.pdf
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rather, some or all of the activities provided under home visiting programs can be considered to
be appropriate, allowable strategies for accomplishing the program’s overall goals.
HHS programs that have or may be used to support home visiting programs include a number
authorized under the Social Security Act as well as other acts. Social Security Act programs that
have been used to support home visiting include Temporary Assistance for Needy Families
(TANF, Title IV-A), Stephanie Tubbs Jones Child Welfare Services (Title IV-B, Subpart 1),
Promoting Safe and Stable Families (Title IV-B, Subpart 2), Maternal and Child Health Block
Grant (Title V), Social Services Block Grant (SSBG, Title XX), Medicaid (Title XIX), and the
Children’s Health Insurance Program (CHIP, Title XXI). Programs authorized in other acts
include the Community-Based Child Abuse Prevention Program (CBCAP, Title II of CAPTA),
Early Head Start (Head Start Act), the Child Care and Development Fund (Child Care and
Development Block Grant Act and Title IV-A of the Social Security Act), the Community
Services Block Grant (Community Services Block Grant Act), Healthy Start (Section 330H of the
Public Health Service Act), and the Adolescent and Family Life Care Demonstration Grants (Title
XX of the Public Health Service Act). 26
Among the ED programs that support home visiting are the Infants and Toddlers Program
authorized by Part C of the Individuals with Disabilities Education Act, as well as several
programs that are authorized under the Elementary and Secondary Education Act (ESEA). ESEA
programs that may support home visiting include Even Start (Title I, Part B), Education for the
Disadvantaged (Title I, Part A), and the Parental Information and Resource Centers (PIRC, Title
V, Part D).
In addition to HHS and ED, several other federal agencies administer programs that have
provided financial support for home visiting programs. Among these are the Office of Juvenile
Justice and Delinquency Prevention (OJJDP) at the U.S. Department of Justice, which has
supported home visiting through initiatives such as Safe Start;27 the Corporation for National and
Community Service, an independent agency which supports home visiting through AmeriCorps
programs;28 and the Department of Defense, which funds home visiting efforts as part of its New
Parent Support Program for families with children ages 0-3.29
Table 3 parses these federal programs into one of two categories based on how home visiting
activities relate to the program goals or statute. The first category lists programs for which home
visitation is either a mandatory program component (e.g., Even Start30) or an explicitly permitted
26 CRS consulted a variety of sources, including Healthy Families America, How are Healthy Families America
Programs Funded?, 2002; Kay Johnson, No Place Like Home: State Home Visiting Policies and Programs, Johnson
Consulting Group, Inc. with support from The Commonwealth Fund, May 2001 (hereinafter Johnson, No Place Like
Home, 2001); and Steffanie Clothier and Julie Poppe, Early Care and Education State Budget Actions FY2007 and
FY2008, National Conference of State Legislatures, April 2008 (hereinafter Clothier and Poppe, Early Care and
Education, 2008).
27 For a program summary of the Safe Start initiative see http://ojjdp.ncjrs.org/programs/ProgSummary.asp?pi=15&ti=
&si=&kw=&PreviousPage=ProgResults. For information on a local site’s use of these funds for home visitation, see
information about the Dayton, OH, Safe Start community’s use of the Nurse Family Partnership model (as well as other
intervention strategies) at http://www.safestartcenter.org/pdf/safestartbooklet.pdf.
28 See information on the HIPPY website at http://www.hippyusa.org/site/view/PublicPolicy.pml#americorps, as well
as the HIPPY 2008 Annual Report at http://www.hippyusa.org/site/view/157074_AnnualReport.pml.
29 See on overview of this DOD program at http://www.militaryhomefront.dod.mil/portal/page/mhf/MHF/
MHF_HOME_1?section_id=20.40.500.420.0.0.0.0.0.
30 See Title I, Part B, Subpart 3, Section 1235 of the Elementary and Secondary Education Act, which requires that
(continued...)
Congressional Research Service
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(or recommended) activity for achieving the program’s goals. The latter refers to programs like
Early Head Start, for which home-based programs are a primary strategy31 for achieving program
goals and are explicitly detailed in statute and regulation. This first category also includes
programs such as Community-Based Child Abuse Prevention grants, for which “voluntary home
visiting” services are considered one of several possible core resource and support services for
families. The second category includes a selection of programs that have broadly stated goals and
authorities; while home visiting is not explicitly required or permitted for these programs, their
expansive and flexible nature may allow them to fund some or all home visiting services. For
instance, home visiting services could be funded through Temporary Assistance for Needy
Families (TANF) programs as a strategy to meet the program’s goal of providing “assistance to
needy families so that children may be cared for in their own homes or in the homes of relatives.”
While programs in this category may support home visiting activities, it is not necessary for them
to do so. Moreover, even if funds from these programs are used to support home visiting
activities, they may account for only a very small portion of total spending.
The list of federal programs in Table 3 is illustrative only. It is not meant to be exhaustive, nor is
it meant to be an exact typology. Rather, it is intended to suggest how strongly home visiting may
be linked to current programs, either through common practice or program rules. Descriptions of
the programs listed in the first category of the table are included in Appendix A of this report.
Table 3. Selection of Federal Funding Streams by Administering Agency and How
Program Funds May Be Used to Support Early Childhood Home Visiting
Department–
Home Visiting Is Explicitly
Home Visiting May Be Supported
Agency
Permitted or Required for
Under Broadly Stated Program Goals
Achieving Program Goals
Department of Health and
- Early Head Start
- Temporary Assistance for Needy Families
Human Services–
- ACF Home visitation Initiative
- Child Welfare Services
- Community-Based Child Abuse
- Social Services Block Grant
Administration for Children and
Prevention (CAPTA, Title II)
- State Grants (CAPTA, Sec. 106)
Families (ACF)
- Promoting Safe and Stable
- Community Services Block Grant
Families
- Child Care and Development Fund
Department of Health and
-
Medicaid
Human Services–
- Children’s Health Insurance Program
Centers for Medicare and Medicaid
(CMS)
Department of Health and
- Healthy Start
Human Services–
- Maternal and Child Health Block
Grant
Health Resources and Services
Administration (HRSA)
(...continued)
programs “provide and monitor integrated instructional services to participating parents and children through home-
based programs.”
31 In 2006, home-based programs accounted for about 41% of Early Head Start programs. Center-based programs
accounted for 51%. Combined, these two program options accounted for approximately 92% of Early Head Start
programs. The remaining programs were combination programs (4%), family child care settings (3%), and locally
designed programs (2%). For more information, see http://www.clasp.org/publications/ehs_pir_2006.pdf.
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Department–
Home Visiting Is Explicitly
Home Visiting May Be Supported
Agency
Permitted or Required for
Achieving Program Goals
Under Broadly Stated Program Goals
Department of Health and
- Adolescent Family Life Care
Human Services–
Demonstration Grants
Office of Population Affairs
Department of Education–
- Even Start
- Education for the Disadvantaged
(Title I, ESEA)
Office of Elementary and
Secondary Education (OESE)
Department of Education–
- Parent Information Resource
Centers
Office of Innovation and
Improvement (OII)
Department of Education–
- Infants and Toddlers Program
(Part C, IDEA)
Office of Special Education and
Rehabilitative Services (OSERS)
Department of Justice–
- Safe Start
Office of Juvenile Justice and
Delinquency Prevention
Department of Defense
- New Parent Support Program
Corporation for National and
-
AmeriCorps
Community Service
Source: Prepared by the Congressional Research Service (CRS).
Note: This categorization is meant to be suggestive of levels of attention to, and program fit with, home
visitation rather than an exact typology.
State and Local Funding Sources
State funding sources for early childhood home visiting programs include state general revenues,
TANF maintenance of effort (MOE) funds, and state funds allocated to match federal grant
programs.32 One study published in 2001 found that 44% of the reported home visiting program
budget dollars came from state revenues.33 In addition, programs often tap into state tobacco
settlement dollars to support home visiting programs. This may be due to fortuitous timing, as the
tobacco settlement of 1998 awarded funding to 46 states at a time when home visiting programs
were rapidly emerging across the country. The tobacco settlement required five tobacco
manufacturers to make annual payments to states (allocated by formula) in perpetuity.
Approximately 13 bills were then enacted by state legislatures targeting children’s services with
tobacco settlement funds, and home visiting organizations have encouraged programs to tap into
these resources when seeking state funds.34
32 See Johnson, State-based Home Visiting, 2009, pp. 10-11; Johnson, No Place Like Home, 2001, pp. 12-13; Laura
Galbraith, Proactive Funding Strategies for Home Visitation: A Resource for Counties, National Association of
Counties and Healthy Families America, 2007, pp. 9-10 (hereinafter Galbraith, Proactive Funding, 2007).
33 Johnson, No Place Like Home, 2001.
34 Galbraith, Proactive Funding, 2007.
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While federal and state sources typically provide the largest contributions to program budgets,
local public funds (such as county taxes or school funds) and private funds (such as those from
charitable foundations) also support home visiting efforts.35
Funding Sources by Home Visiting Model
Most home visiting programs are funded by multiple sources. In addition, funding sources appear
to vary by program model and, in some cases, within program models over time.
For instance, a 2004 Healthy Families America (HFA) survey found that 54% of program funding
came from the federal government, 38% came from the state, and 8% came from local sources. 36
This is a change from 2002 and 2003, when HFA survey data suggested that a greater share of the
total funding came from state, rather than federal, funding streams. In 2004, the bulk of federal
funding for Healthy Families America programs came from TANF (86%), with smaller
contributions from Title IV-B programs (e.g., Child Welfare Services, Promoting Safe and Stable
Families), CAPTA, and other federal sources. This reported composition of federal funding
sources also represents a change from prior years. HFA data indicate that in FY2003 the sources
of federal funding were more balanced, with Title IV-B programs representing about 35% and
TANF accounting for about 28% of total federal funding.37 Results from these annual Healthy
Families America surveys also suggest that funding for HFA programs has decreased over time,
from nearly $296 million in FY2002 to almost $185 million in FY2004. Notably, results from
these surveys represent only a subset of all HFA programs (due to a response rate of about 73%).
While these survey data may provide useful insight into Healthy Families America budgets, they
should not be interpreted as reflecting a comprehensive picture of HFA funding. Moreover, the
results of these HFA surveys should not be generalized to other home visiting program models, as
the sources of federal funding may differ across programs, depending on the program model’s
origin and primary focus. Healthy Families America, for example, was launched in 1992 by
Prevent Child Abuse America38 with an explicit emphasis on preventing child abuse and neglect.
Thus, it is not surprising that many Healthy Families America sites appear to receive more
support from HHS human services programs (e.g., Title IV-B programs, TANF, CAPTA), while
programs like the Nurse Family Partnership, by contrast, report significant support from public
health programs at HHS (e.g., Medicaid, Maternal and Child Health Block Grant).
In fact, the original Nurse Family Partnership (NFP) trial study, launched in Elmira, NY, in 1978,
was funded by the Maternal and Child Health Bureau within the Health Resources and Services
Administration (HRSA) at HHS.39 In subsequent years, the Maternal and Child Health Bureau
35 Johnson, State-based Home Visiting, 2009.
36 Includes responses from 33 of 45 states, with a site sample of 398. See http://www.healthyfamiliesamerica.org/
network_resources/hfa_state_of_state_systems.pdf.
37 See http://www.healthyfamiliesamerica.org/network_resources/hfa_state_of_state_systems.pdf. Note that FY2003
results are reported differently in another HFA report at http://www.healthyfamiliesamerica.org/downloads/ssdg8.pdf.
The other report also shows funding from CAPTA outstripping TANF, but the percentages vary, with CAPTA
representing 39% and TANF representing 31% of federal funds in that fiscal year.
38 Prevent Child Abuse America (formerly known as the National Committee to Prevent Child Abuse) launched HFA
in partnership with Ronald McDonald House Charities. HFA also credits the Freddie Mac Foundation with being
instrumental in supporting ongoing development of the program.
39 Andy Goodman, The Story of David Olds and the Nurse Home Visiting Program, Robert Wood Johnson Foundation,
July 2006.
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remained a common source of funding for Nurse Family Partnership programs, though federal
support grew to include grants offered by the National Institutes of Health, as well as programs
such as TANF and Medicaid. Recently, David Olds, founder of the Nurse Family Partnership,
reported during congressional testimony that Medicaid was a growing source of funding for NFP
programs, while the use of TANF funds was decreasing.40 He indicated that states had used TANF
funds more during the program’s start-up phase, but that they now rely more on Medicaid
funding. In his testimony, Olds also pointed to the Maternal and Child Health Block Grant as a
common source of federal support for NFP programs.
In contrast to both Healthy Families America and the Nurse Family Partnership, Parents as
Teachers (PAT) and Home Instruction for Parents of Preschool Youngsters (HIPPY) have both
reported significant financial support from ED programs, such as Education for the
Disadvantaged, Even Start, and Parent Information Resource Centers (all three programs are
funded under the Elementary and Secondary Education Act).41 For instance, the 2005-2006
HIPPY USA End-of-Year Report notes that 120 HIPPY sites received federal funding from ED
programs, compared to only eight sites that reported federal support from HHS (this split is
roughly consistent with data in prior year reports).42 The Parents as Teachers model, meanwhile,
originated largely due to support from the education community. PAT started in 1981 with a pilot
project in Missouri, funded by the state Department of Elementary and Secondary Education and
the Danforth Foundation. Four years later, the Missouri Department of Elementary and Secondary
Education had expanded the PAT program to all school districts across the state. Today, more than
160 Local Education Agencies (LEA) are using Title I funds from ED to support PAT programs.43
In fact, both Parents as Teachers and HIPPY programs are referenced by name in the authorizing
statute for three programs in the Elementary and Secondary Education Act (ESEA). Education for
the Disadvantaged (Title I, Part A) requires that local education agencies coordinate and integrate
their parental involvement strategies under Title I with those provided under other programs, such
as Parents as Teachers and HIPPY.44 Organizations receiving grants through Parent Information
Resource Centers (Title V, Part D) are required to use at least 30% of the funds they receive in
each fiscal year to “establish, expand, or operate Parents as Teachers programs, Home Instruction
for Preschool Youngsters programs, or other early childhood parent education programs.”45 The
Even Start (Title I, Part B) statute allows for the provision of funds to “eligible organizations” for
program improvement and replication activities.46 The statute defines eligible organizations as
“any public or private nonprofit organization with a record of providing effective services to
family literacy providers” and goes on to list Parents as Teachers and HIPPY as examples of such
organizations.
40 See the testimony of David Olds, in U.S. Congress, House Committee on Ways and Means, Subcommittee on
Income Security and Family Support, Health Care for Children in Foster Care, hearings, 110th Cong., 1st sess., July 19,
2007, H-Hrg. 110-(Washington: GPO, 2007), http://waysandmeans.house.gov/hearings.asp?formmode=view&id=7167.
41 Wasserman, Implementation of Home Visitation, 2006. On page 3, Wasserman notes that PIRC grantees are required
to use a minimum of 30% of their awards to establish, expand, or operate early childhood parent education programs
such as PAT and HIPPY. See also Section 5563 of the Elementary and Secondary Education Act (ESEA).
42 See the 2005-2006 HIPPY USA End-of-Year Report online at http://www.hippyusa.org/site/view/
136428_HIPPYEndofYearMISReport.pml.
43 See PAT Fact Sheet at http://www.parentsasteachers.org/atf/cf/%7B00812ECA-A71B-4C2C-8FF3-
8F16A5742EEA%7D/PAT%20and%20Title%20I%20ARRA.pdf.
44 See Title I, Part A, Subpart 1, Section 1118 of the Elementary and Secondary Education Act.
45 See Title I, Part D, Subpart 16, Section 5563 of the Elementary and Secondary Education Act.
46 See Title I, Part B, Subpart 3, Section 1232 of the Elementary and Secondary Education Act.
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Current Investment In and Estimated Costs of Home Visiting
Largely because there is such variety in home visiting program models and the sources that fund
them, it is difficult to estimate the current level of national investment in home visiting programs.
Partial information provided by some states support the assertion that no less than $250 million47
is currently being spent each year on home visitation and one researcher has estimated total
annual spending for this purpose (from all sources) at “perhaps $750 million to $1 billion.”48
Based on reporting from 31 states in the study conducted by the National Center for Children in
Poverty (NCCP), the aggregate annual level of support for home visiting programs in responding
states in 2007 was more than $250 million (covering about 55 programs).49 This figure represents
only a partial accounting of spending for early childhood home visitation, however, because it
does not include funding for programs operating in states that did not respond to this survey
question and it does not capture spending on programs that did not meet the definition of “state-
based” used in the NCCP report.
A survey of state appropriations for “parent education and home visiting” programs (including
some Healthy Families America, Nurse Family Partnership, HIPPY, and Parents as Teachers
programs) conducted by the National Conference of State Legislatures (NCSL) found that among
the 26 responding states a total of about $250 million was appropriated for FY2007 and $281
million for FY2008.50 Of this total, it appears that federal funding sources account for roughly
15% of total appropriations, with most federal contributions attributed to TANF or Medicaid. The
NCSL report is likely to under-represent federal contributions, as not all federal programs require
state legislative action in order to be directed toward services at the state or local level.
Taking a broader view of home visiting programs across the United States, home visitation
researcher Deanna Gomby estimated in a 2005 report that annual costs for these programs are
“perhaps $750 million to $1 billion.” Gomby’s estimate assumes a range of $1,000 to $3,000 per
family per year and is based on the number of children enrolled in seven selected home visiting
programs operating nationally.51
Estimating costs for home visiting is also difficult because costs may vary significantly by
program model and site, as demonstrated in Table 1. For example, Healthy Families America
estimates that their programs spent from $1,950 to $5,768 per family in FY2004, with costs
averaging about $3,348 per family in that year.52 This was up from an average cost of $2,764 in
FY2003, when spending ranged from $1,550 to $4,500 per family. The Nurse Family Partnership
offers more current numbers in a 2009 fact sheet, indicating that their typical costs range from
47 Consistent with Johnson, State-based Home Visiting Programs, 2009, p. 4, and with Clothier and Poppe, Early Care
and Education, 2008, Appendix C.
48 Gomby, Home Visitation, 2005, p. 1.
49 Johnson, State-based Home Visiting Programs, 2009, p. 4.
50 Clothier and Poppe, Early Care and Education, 2008, Appendix C.
51 Gomby, Home Visitation, 2005, p. 1. Gomby’s calculations are based on numbers of children enrolled in “the seven
largest home visiting programs nationally” (as determined by Gomby). These include Even Start, Early Head Start,
Parents As Teachers, HIPPY, Healthy Families America, Nurse-Family Partnership, and the Parent-Child Home
Program. Gomby assumes some duplication in counts across the programs (at least 45% for PAT) and then assumes a
range of $1,000 to $3,000 per family per year.
52 See HFA website at http://www.healthyfamiliesamerica.org/network_resources/hfa_state_of_state_systems.pdf.
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$2,914 to $6,463 per family per year.53 Variation in costs across program models and sites can be
attributed to a number of factors, including the intensity of services provided (e.g., number of
visits), the qualifications and salary requirements of staff, the differences in cost of living for
communities across the country, and the variety and scope of services offered. Typically, the more
comprehensive the program, the higher the cost.54 The average cost for a slot in Early Head Start,
for instance, is estimated to exceed $11,000 annually (though this average is based on all Early
Head Start programs, which include center-based, home-based, and combination programs).55
Research and Evaluation of Existing Home
Visiting Programs
Looking at findings across multiple home visiting studies, researchers conclude that home
visiting can provide benefits to children and their parents, including preventing potential child
abuse and neglect, enhancing cognitive development, improving parenting attitudes and parenting
behaviors (e.g., discipline strategies), and increasing maternal education. They caution, however,
that while all of those positive effects for home visiting programs were statistically significant,
the size of the effect is small. (That is to say, the difference between observed outcomes for home
visited as opposed to not-visited parents and children is small.) Further, while one or more
individual studies may have shown positive effects with regard to many other desired outcomes,
those effects have not necessarily been studied and/or achieved across more than one study or
program site.56 Efforts to better understand the components of successful home visitation and to
find additional effective methods for meeting a range of family and child needs continue with
newer research providing additional information on positive outcomes.57
In sum, most researchers seem confident that early childhood home visitation can be effective in
improving outcomes for families and children, although they differ on how strong they think this
evidence is across the range of program models and across the variety of outcomes. Other
researchers caution that to be effective (regardless of program model or goal) a home visitation
program’s goals must be aligned with the program’s content (e.g., if you want to prevent child
abuse and neglect you have to focus on the aspect(s) of the home visit that will accomplish this),
and that home visitors must appropriately and adequately deliver the services. They also make
clear that home visiting is not a silver bullet strategy that can solve all prevention needs. Instead
they suggest it will be most successful if it is integrated into a broader set of services that are
focused on supporting families and ensuring positive outcomes for young children. These include
quality center-based education for preschoolers, preventive health care as part of medical homes58
53 See NFP website at http://www.nursefamilypartnership.org/resources/files/PDF/Fact_Sheets/NFP_Benefits&
Cost.pdf.
54 Galbraith, Proactive Funding, 2007, p. 4.
55 See FY2008 Head Start Program Fact Sheet online at http://eclkc.ohs.acf.hhs.gov/hslc/About%20Head%20Start/
dHeadStartProgr.htm.
56 Monica A. Sweet and Mark I. Appelbaum, “Is Home Visiting an Effective Strategy? A Meta-Analytic Review of
Home Visiting Programs for Families with Young Children,” Child Development, vol. 75, no. 5 (September/October
2004), pp. 1435-1456 (hereinafter Sweet and Appelbaum, “A Meta-Analytic Review,” 2004); and Gomby, Home
Visitation, 2005.
57 Testimony of Deborah Daro before House Ways and Means Committee, Subcommittee on Income Security and
Family Support, June 9, 2009, available at http://waysandmeans.house.gov/hearings.asp?formmode=view&id=7842.
58 As currently used, a “medical home” means provision of primary care in a manner that is “accessible, continuous,
(continued...)
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for all children, parenting support groups, and clinical mental health and other treatment services
for parents who need them. Finally, they seek continued study of programs to understand what is
most effective and they urge that programs be implemented in a manner that permits continuous
quality improvement. 59
Methods for Evaluating Program Models
There is a fairly large and growing body of research looking at a variety of home visiting
programs. Some of these studies have been designed as randomized control trials. Findings
generated from these experiments, provided they are well designed and implemented, can
demonstrate the level of effectiveness. In this kind of program evaluation, study participants are
randomly assigned to a “treatment” or “experimental” group, while others are randomly assigned
to a “control” group. Families assigned to the “treatment” group subsequently receive home
visiting services; families assigned to the control group do not. The outcomes for both groups are
tracked and tested for statistically significant differences. To ensure that the findings accurately
reflect what is achieved, however, these studies must have a participant pool that is large enough
to allow researchers to draw conclusions that are statistically significant. Finally, the experiment
should be carried out in more than one site and the findings of the study should be consistent (or
replicated) across those multiple sites. Follow-up studies (longitudinal analysis) of the original
may be used to determine if any initial positive effects are maintained over time and/or to
measure later effects (e.g., academic success in grade school of home visited versus not-visited
infants and toddlers).
Other studies that have been used to evaluate home visitation programs are referred to as “quasi-
experimental.” Although they do not randomly assign participants, quasi-experimental studies are
designed so that outcomes for the group of families and children receiving the treatment (e.g.,
home visiting) may be compared to a group of families who did not receive these services.
Ideally, the characteristics of this comparison group closely match those of the group receiving
the treatment (home visiting services) so that any differences are fairly attributed to the treatment
received rather than to differences in the groups studied. As with randomized control tests,
findings from quasi-experimental studies that use larger participant pools and test outcomes in
more than one location are considered of greater merit than those not meeting these standards.
(...continued)
comprehensive, family centered, coordinated, compassionate, and culturally effective.” As part of this concept, primary
care providers are expected to coordinate with other health, education, and family support professionals to ensure a
child and his/her family access to, and coordination of, specialty health care, educational services, family support in
and out of home care, and other public and private community services important to the overall health of the child and
his/her family. See Children’s Health Topics, “Medical Home,” American Academy of Pediatrics at
http://www.aap.org/healthtopics/medicalhome.cfm.
59 Council on Community Pediatrics, “The Role of Preschool Home Visiting Programs in Improving Children’s
Developmental and Health Outcomes,” Policy Statement, Pediatrics, vol. 123, no. 2 (February 2009), pp. 598-603
(hereinafter Council on Community Pediatrics, “The Role of Preschool Home Visiting Programs,” 2009). Johnson,
State-based Home Visiting Programs, 2009. Deanna S. Gomby, “The Promise and Limitations of Home Visiting:
Implementing Effective Programs,” Child Abuse & Neglect, vol. 31 (2007), pp. 793-799. Deborah Daro, Home
Visitation: Assessing Progress, Managing Expectations, Ounce of Prevention and Chapin Hall Center for Children,
University of Chicago, 2006. Lisa Thompson et al., Home Visiting: A Service Strategy to Deliver Proposition 10
Results, UCLA Center for Healthier Children, Families and Communities, December 2001 (hereinafter Thompson et
al., Home Visiting: A Service Strategy, 2001).
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Finally, some evaluations of home visitation programs look at changes across time (e.g., pre-test,
post-test) but only among the group of families who were served. This kind of program feedback
can be important in implementing a program—particularly if consistent data are regularly
collected and reviewed as part of a structured and continuous program improvement process.
However, this type of study is considered “non-experimental” because it lacks a contemporaneous
comparison group, and some of the changes observed could have occurred even without
implementing home visiting.
Randomized control studies may provide the clearest evidence of a home visiting program’s
effects, and some researchers call for continued implementation of these studies to ensure
effectiveness of home visiting models.60 Others note that randomized control studies are
expensive and time consuming, and that they require social service providers to withhold what
may be valuable family support from “control group” members.61 Reflecting on their own efforts
to implement a randomized control trial of a particular service strategy for children and families,
two researchers at the Michigan State University Child Health Care Clinic note that these trials
are based on three assumptions—standardized interventions, equal groups, and equal
environments—and that “most if not all, of these assumptions are difficult to meet in the complex
environment of practice.”62 Some researchers and home visitation advocates cite the wide range
of family needs and circumstances as dictating that more than one model of home visiting is
necessary and they further argue that each of those iterations can not be tested, practically, in a
random trial.63 Instead, these researchers assert that the overall efficacy of home visiting has been
proven and therefore efforts should be placed on fine tuning existing program models to ensure
their quality and monitor outcomes.64
Research Findings by Desired Program Outcomes
As discussed above, home visiting programs have goals that cross several major domains,
including maternal and child health; early childhood social, emotional, and cognitive
development; and family/parent functioning. Programs may identify one or more desired
outcomes across one or more of these main domains. In the maternal and child health domain,
desired program outcomes may include decreased infant mortality and improved infant health and
physical development; improved perinatal maternal health and health behaviors; a reduced
number of subsequent pregnancies and/or a longer time interval between pregnancies; and
prevention of child injuries, intentional or unintentional. In the early childhood development
domain, desired program outcomes may include improved parent-child interaction to enhance and
ensure children’s social/emotional and cognitive development; enhanced school readiness for
children and longer-term academic success. Finally, in the domain of family/parent functioning,
home visitation programs may seek to improve parenting skills, knowledge, and behaviors;
reduce the incidence of child abuse or neglect; and increase maternal education attainment and
family self sufficiency.
60 Harriet L. MacMillan et al., “Interventions to Prevent Child Maltreatment and Associated Impairment,” The Lancet,
vol. 373 (January 17, 2009), p. 261 (hereinafter, MacMillian, et al, “Interventions,” 2009).
61 Wasserman, Implementation of Home Visitation, 2006.
62 Rebecca Anne Malouin and Jane Turner, Letter to the Editor, “A Review of the Evidence for the Medical Home of
Children with Special Health Care Needs,” Pediatrics, vol. 123, no. 2 (February 2009), p. e369.
63 Question and Answer Period, NCCP “Focus on Home Visiting,” webinar, 2008.
64 Ibid. Johnson, State-based Home Visiting, 2009.
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A variety of factors have been cited as important to the effectiveness of home visiting generally
without regard to the model being employed or outcome sought. These include, but are not
limited to, clear program goals that are tied to program content; educational status and training of
the home visitors; intensity and duration of service provision, including the ability to attract and
retain families; and integration of the program with other kinds of parenting support programs
and early childhood programs related to children’s health, education, and socio-emotional
development.65
There is a large and still growing body of research on home visitation programs. Some of the
findings to date are discussed below.
Findings in the Maternal and Child Health Domain
A number of home visiting studies have considered the effectiveness of these programs in
improving maternal and child health outcomes, including maternal mental health and substance
abuse (during or after pregnancy), the number and spacing of subsequent pregnancies, the
incidence of preterm and low birth weight babies, use of preventive/well-child care, and
frequency of emergency room treatment or injuries among children.
A 2004 meta-analysis found that home visiting programs could be effective in reducing, for
children, the number of emergency room visits, injuries or ingestions treated, and accidents
requiring medical attention.66 In her 2005 review of the research on home visitation, however,
Deanna Gomby concluded that home visitation programs had not been shown to increase the use
of preventive health care.67 With regard to outcomes for mothers, some home visitation programs,
discussed below, have been shown to reduce the number of subsequent pregnancies or to increase
the time interval between pregnancies. Researchers have identified maternal depression,
substance abuse, and intimate partner violence as critical issues that home visitors have not
necessarily known how to identify or address, and that may, in turn, reduce the effectiveness of
home visitation on other outcomes.68
Maternal Mental Health and Substance Abuse
Maternal mental health and substance abuse can have significant implications for both mother
and child. For instance, research shows that clinical depression can be a barrier to employment
and that it can affect interactions between mother and child. In fact, poor maternal mental health
65 Gomby, “The Promise and Limitations of Home Visiting,” 2007. Testimony of Jeanne Brooks-Gunn and Testimony
of Deborah Daro before U.S. House Ways and Means Committee, Subcommittee on Income Security and Family
Support, “Hearing on Proposals to Provide Federal Funding for Early Childhood Home Visitation Programs,” June 9,
2009. See http://waysandmeans.house.gov/hearings.asp?formmode=detail&hearing=682.
66 Sweet and Appelbaum, “A Meta-Analytic Review,” 2004.
67 Gomby, Home Visitation, 2005, pp. 18-19.
68 S. Darious Tandon et al., “Formative Evaluation of Home Visitors’ Role in Addressing Poor Mental Health,
Domestic Violence, and Substance Abuse Among Low-Income Pregnant and Parenting Women,” Maternal and Child
Health Journal, vol. 9, no. 3 (September 2005), pp. 273-283. Robert T. Ammerman et al., “Changes in Depressive
Symptoms in First Time Mothers in Home Visitation,” Child Abuse & Neglect, vol. 33 (2009), pp. 127-138. John
Eckenrode et al., “Preventing Child Abuse and Neglect with a Program of Nurse Home Visitation: The Limiting
Effects of Domestic Violence,” Journal of the American Medical Association, vol. 284, no. 11 (September 2000), pp.
1385-1390.
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has been linked to higher rates of behavioral, academic, and health problems among children.69
Meanwhile, studies have shown that prenatal exposure to alcohol or drugs can increase the risk of
preterm birth, miscarriage, and birth defects, including physical, cognitive, and behavioral
disorders.70 Despite this, data from the combined 2006-2007 National Survey on Drug Use and
Health show that substance usage among pregnant women ages 15 to 44 is prevalent, with an
average of 5.2% reporting use of illicit drugs in the past month, 16.4% indicating cigarette use in
the past month, and 11.6% reporting current alcohol use.71
A randomized trial study of the Hawaii Healthy Start Program (generally acknowledged as the
prototype for Healthy Families America) concluded that there were positive maternal mental
health outcomes for participating mothers compared to the control group in one of the three
Hawaii Healthy Start programs operating in Hawaii.72 The same Hawaii Healthy Start Program
study found that home visitation had no statistically significant effect on maternal substance
abuse.73 However, when isolating families receiving a higher dose of services, this study
concludes that, compared to control group mothers, those who received a higher dose of home
visiting services did demonstrate reduced maternal “problem alcohol use.”74 This suggests that
intensity and duration of services may be critical factors in determining program success.
Results from a randomized control trial of the Nurse Family Partnership model in Denver, CO,
concluded that two years after the program of home visits was completed, mothers who had been
visited by paraprofessionals exhibited better mental health (on a standardized scale) than did
control group mothers in the study. However, there was no statistically significant difference for
nurse-visited mothers (compared to control group mothers) on mental health outcomes. Neither
nurse-visited nor paraprofessional-visited mothers in Denver showed statistically significant
outcomes that were different from control group mothers with regard to substance abuse.75 The
nine-year follow-up to the NFP’s program in Memphis, TN, found that nurse-visited mothers
used fewer substances.76 However, this evaluation found no statistically significant effect on
maternal depression.
69 Surjeet K. Ahluwalia, Sharon M. McGroder, and Martha J. Zaslow et al., Symptoms of depression among welfare
recipients: A concern for two generations, Child Trends Research Brief, December 2001. Gomby, Home Visitation,
2005.
70 Katrine Albertsen et al., “Alcohol consumption during pregnancy and the risk of preterm delivery,” American
Journal of Epidemiology, vol. 159, no. 2 (2004), pp. 155-161. Also see the 2005 press release from the U.S. Surgeon
General’s Office, online at http://www.surgeongeneral.gov/pressreleases/sg02222005.html, and the fact sheet by the
March of Dimes Foundation online at http://www.marchofdimes.com/professionals/14332_1170.asp.
71 U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services
Administration (SAMHSA), Results from the 2007 National Survey on Drug Use and Health: National Findings,
NSDUH Series H-34, HHS Publication No. SMA 08-4343, September 2008, pp. 4, 24, 33.
72 Anne Duggan, Loretta Fuddy, and Lori Burrell et al., “Randomized trial of a statewide home visiting program to
prevent child abuse: Impact in reducing parental risk factors,” Child Abuse & Neglect, vol. 28, no. 6 (June 2004) pp.
630-632 (hereinafter Duggan et al., “Impact in reducing parental risk factors,” 2004).
73 Duggan et al., “Impact in reducing parental risk factors,” 2004, pp. 630-631. Anne K. Duggan, Elizabeth C.
McFarlane, and Amy M. Windham et al., “Evaluation of Hawaii’s Healthy Start Program,” The Future of Children,
vol. 9, no. 1 (Spring/Summer 1999), p. 84 (hereinafter Duggan et al., “Hawaii’s Healthy Start Program,” 1999).
74 Duggan et al., “Impact in reducing parental risk factors,” 2004, p. 631.
75 David L. Olds et al., “Effects of Home Visits by Paraprofessionals and by Nurses: Age 4 Follow-Up Results of a
Randomized Trial,” Pediatrics, vol.. 114, no. 6 (December 2004), pp. 1560-1568.
76 David L. Olds et al., “Effects of Nurse Home Visiting on Maternal and Child Functioning: Age-9 Follow-Up of a
Randomized Trial,” Pediatrics, vol. 120, no. 4 (October 2007), pp. e841.
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Number and Frequency of Subsequent Pregnancies
Some researchers argue that “rapid successive pregnancies” can negatively affect mothers’
educational and workforce achievements.77 Several studies have looked at the effectiveness of
home visiting programs on maternal health outcomes.
Research on the Nurse Family Partnership site in Elmira, NY, found that by the child’s fourth
birthday (two years after program ended) nurse-visited mothers had fewer subsequent
pregnancies.78 Results from studies at the NFP site in Memphis found that four years after the
program ended nurse-visited mothers had experienced fewer subsequent pregnancies. This study
also found evidence of longer intervals between births of the first and second child.79 The follow-
up to this study found that nine years after the intervention, these results held; on average, nurse-
visited women had longer intervals between the births of first and second children and fewer
cumulative subsequent births per year.80 Notably, while both sites showed effects on reducing
subsequent pregnancies, the effect size was much larger in Elmira (67% reduction) than in
Memphis (23% reduction).81 A study from the Denver NFP site found that, among the nurse-
visited mothers who had at least one additional child (within four years of their first pregnancy),
there was a greater interval between that pregnancy and the first one, compared to the control
group. However, this same study found no statistically significant difference for paraprofessional-
visited mothers (compared to control group mothers) in birth intervals and that neither nurse-
visited nor paraprofessional-visited mothers showed statistically significant outcomes that were
different from control group mothers with regard to the number of subsequent pregnancies.82
A randomized control trial among teen mothers in California of the Parents as Teachers home
visiting model found that significantly fewer home visited mothers had multiple pregnancies
during the study period than did control group mothers (1.4% versus 4.8%). 83 By contrast, the
randomized trial evaluation of the Hawaii Healthy Start program showed no effects on repeat
births.84
77 David L. Olds, Charles R. Henderson, Jr., and Harriet J. Kitzman et al., “Prenatal and Infancy Home Visitation by
Nurses: Recent Findings,” The Future of Children, vol. 9, no. 1 (Spring/Summer 1999), p. 44.
78 Research cited in RAND Corp., Promising Practices Network, Programs that Work, Nurse Family Partnership,
http://www.promisingpractices.net/program.asp?programid=16#findings.
79 David L. Olds et al., “Effects of Nurse Home Visiting on Maternal Life Course and Child Development: Age 6
Follow-Up Results of A Randomized Trial,” Pediatrics, vol. 114, no. 6 (December 2004), pp. 1550-1559.
80 David L. Olds et al., “Effects of Nurse Home Visiting on Maternal and Child Functioning: Age-9 Follow-Up of a
Randomized Trial,” Pediatrics, vol. 120, no. 4 (October 2007), pp. e838-e840.
81 David L. Olds, Charles R. Henderson, Jr., and Harriet J. Kitzman et al., “Prenatal and Infancy Home Visitation by
Nurses: Recent Findings,” The Future of Children, vol. 9, no. 1 (Spring/Summer 1999), p. 61.
82 David L. Olds et al., “Effects of Home Visits by Paraprofessionals and by Nurses: Age 4 Follow-Up Results of a
Randomized Trial,” Pediatrics, vol.. 114, no. 6 (December 2004), pp. 1560-1568.
83 Mary Wagner et al., Intervention in Support of Adolescent Parents and Their Children: A Final Report on the Teen
Parents as Teachers Demonstration, SRI International, 1996. (As reported by the RAND Corp., Promising Practices
Network, Program that Work at http://www.promisingpractices.net/program.asp?programid=88#findings.)
84 Samer S. El-Kamary, Susan M. Higman, and Elizabeth McFarlane et al., “Hawaii’s Healthy Start home visiting
program: Determinants and impact of rapid repeat birth,” Pediatrics, vol. 114, no. 3 (September 2004), pp. e317-e326.
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Healthy Birth Weight
Birth weight can be another important indicator of maternal and child health. Low birth weight is
a leading cause of infant deaths and childhood illnesses and disabilities.85 Several home visiting
studies have looked at outcomes in this area. For instance, nurse-visited young adolescents (ages
14 to 16) in the Nurse Family Partnership’s Elmira study had babies who were an average of 395
grams heavier than the babies of adolescents in the comparison group.86 In the nine-year follow-
up of the Memphis site, researchers found a significantly lower number of subsequent low birth
weight infants (0.18 versus 0.27).87
The randomized control trial of teen mothers in California found that among those who entered
the study while pregnant, mothers in the PAT-only group had marginally lower rates of low birth
weight babies than did mothers in the control group (4% versus 8%).88 In addition, a study of the
Healthy Families America program in New York found that, of those who began participating in
the Healthy Families America program at least two months prior to the birth of their children,
control group mothers were significantly more likely to deliver low birth weight babies than were
participating mothers. The rate of low birth weight was two-and-a-half times higher for the
control group (8.3%) than it was for participating mothers (3.3%).89 However, it is worth noting
that this study found no significant program effects on the rate of premature births or the
percentage of babies requiring neonatal intensive care.
Adequacy of Preventative Health Care
Many home visiting studies have looked at outcomes related to children’s health, including access
to health insurance, primary care physicians, well-child visits, and immunization rates.
A study of the New York Healthy Families America program found that parents in the control
group were significantly less likely than participating parents to have health insurance for their
children as of the first-year follow-up interview (90.4% compared to 93.9%).90 There was no
program effect, however, on the parents’ likelihood of having health insurance coverage for
themselves. There were also no significant differences between the participating families and
85 Susan Mitchell-Herzfeld et al., Evaluation of Healthy Families New York (HFNY): First Year Program Impacts,
New York State Office of Children and Family Services, Bureau of Evaluation and Research, and the Center for
Human Services Research, University at Albany, February 2005, p. vii, http://www.ocfs.state.ny.us/main/prevention/
assets/HFNY_FirstYearProgramImpacts.pdf.
86 David L. Olds et al., “Improving the Delivery of Prenatal Care and Outcomes of Pregnancy: A Randomized Trial of
Nurse Home Visitation,” Pediatrics, vol. 77, no. 1 (January 1986), pp. 16-28.
87 David L. Olds et al., “Effects of Nurse Home Visiting on Maternal and Child Functioning: Age-9 Follow-Up of a
Randomized Trial,” Pediatrics, vol. 120, no. 4 (October 2007), pp. e832-e845.
88 Mary Wagner et al., Intervention in Support of Adolescent Parents and Their Children: A Final Report on the Teen
Parents as Teachers Demonstration, SRI International, 1996. (As reported by the RAND Corp., Promising Practices
Network, Program that Work at http://www.promisingpractices.net/program.asp?programid=88#findings.)
89 Susan Mitchell-Herzfeld et al., Evaluation of Healthy Families New York (HFNY): First Year Program Impacts,
New York State Office of Children and Family Services, Bureau of Evaluation and Research, and the Center for
Human Services Research, University at Albany, February 2005, pp. 47-50, http://www.ocfs.state.ny.us/main/
prevention/assets/HFNY_FirstYearProgramImpacts.pdf.
90 Susan Mitchell-Herzfeld et al., Evaluation of Healthy Families New York (HFNY): First Year Program Impacts,
New York State Office of Children and Family Services, Bureau of Evaluation and Research, and the Center for
Human Services Research, University at Albany, February 2005, pp. 50-51, http://www.ocfs.state.ny.us/main/
prevention/assets/HFNY_FirstYearProgramImpacts.pdf.
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control group families in outcomes related to the child having a regular health care provider, the
child ever having been without needed medical care, the number of well-child visits, and
completion of all immunizations.
Meanwhile, results from the second-year follow-up on the random trial study of the Hawaii
Healthy Start Program indicate that participating parents were statistically more likely to describe
themselves as having a primary care provider who handles most of their child’s health care needs
and understands their concerns about their child’s health.91 However, this same study found no
differences in the rates of immunization or well-child visits for participating children compared to
control group children.92 By contrast, in a third-year follow-up of a randomized control study of
the Parents as Teachers program (one site only), participating children were significantly more
likely to be fully immunized than control group children.93
To gain the most health benefits for young children, researchers have also looked at the
importance of linking home visiting with quality pediatric care, including establishment of a
medical home94 for all children.95
Need for Urgent Care or Hospitalization
Child health and safety can also be linked to need for urgent care, hospitalization, or frequency of
ingestions or injuries. Research on the Nurse Family Partnership site in Elmira, NY, found that at
the program’s end (when children were two years old), children in nurse-visited homes had fewer
emergency room visits for injuries and ingestions than did children in homes of control group
mothers, as well as fewer emergency room visits overall when compared to those children.96
Results from the Memphis NFP site suggest that at the end of the program (when the child was
two years old) nurse-visited children had fewer health care encounters for injuries and ingestions
compared with control group children.97
By contrast, the Hawaii Healthy Start study reported that children participating in the program
experienced no beneficial effect with respect to emergency room use, hospitalization, and need
for urgent medical care when compared to children in the control group.98
91 Duggan et al., “Hawaii’s Healthy Start Program,” 1999, pp. 77, 80.
92 Deanna S. Gomby, Patti L. Culross, and Richard E. Behrman, “Home Visiting: Recent Program Evaluations—
Analysis and Recommendations,” The Future of Children, vol. 9, no. 1 (Spring/Summer 1999), p. 12.
93 Mary Wagner et al., The Multisite Evaluation of the Parents as Teachers Home Visiting Program: Three-Year
Findings From One Community, SRI International, August 2001.
94 See footnote 58 for an explanation of the “medical home” concept.
95 Council on Community Pediatrics, “The Role of Preschool Home Visiting,” p. 601. Thompson et al., Home Visiting:
A Service Strategy, 2001, p. 27.
96 David L. Olds, et. al., “Does Prenatal and Infancy Nurse Home Visitation Have Enduring Effects on Qualities of
Parental Caregiving and Child Health at 24 to 50 months of Life?” Pediatrics, vol. 93, no. 1 (January 1994), pp. 89-98.
97 Harriet Kitzman, et.al., “Effects of Prenatal and Infancy Home Visitation by Nurses on Pregnancy Outcomes,
Childhood Injuries, and Repeated Childbearing: A Randomized Controlled Trial,” Journal of the American Medical
Association, vol. 278, no. 8 (1997), pp. 644-652. (As cited in RAND Corp, Promising Practices Network, Programs that
Work, Nurse Family Partnership, http://www.promisingpractices.net/program.asp?programid=16#findings.)
98 Duggan et al., “Hawaii’s Healthy Start Program,” 1999, p. 82.
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Findings in the Child Social, Emotional, and Cognitive Development Domain
A number of studies of home visiting programs have evaluated program effectiveness in
enhancing children’s social, emotional, and cognitive development. Among other things, these
outcomes may be manifested in early language skills and behaviors, as well as school-aged
academic achievement, and matriculation rates. Overall, most analyses conclude that cognitive
and socio-emotional outcomes were stronger for home visited children than for control group
children.99 However, researchers caution that the effect sizes for child development outcomes
were usually small to medium at best, noting that home visited children might see improved
scores on a standardized intelligence test of only a few points.
School Readiness and Achievement
As reported in Deanna Gomby’s 2005 paper, some studies of home visiting programs such as
Parents as Teachers,100 HIPPY,101 or the Parent-Child Home Program102 have demonstrated that
home visited children outperform other children in the community through the 4th, 6th, or 12th
grades, respectively, in measures such as school grades and achievement test scores on reading
and math, suspensions, or high school graduation rates.103 However, large cognitive benefits such
as these are not always demonstrated reliably in high-quality randomized control trials of home
visiting programs.
Many evaluations of Nurse Family Partnership programs do not assess child cognitive
development outcomes. However, some studies of the randomized control trials in Elmira, NY,
and Memphis, TN, suggest very limited to no significant program effects on children’s cognitive
development and intellectual functioning.104 By contrast, the nine-year follow-up study of
participants in the Nurse Family Partnership’s program in Memphis found that nurse-visited
children born to low-resource mothers had grade point averages (GPAs) that were equivalent to
those of control group children who were born to high-resource mothers.105 In contrast, control
99 Lynn A. Karoly, M. Rebecca Kilburn, and Jill S. Cannon, Early Childhood Interventions: Proven Results, Future
Promise, RAND Corporation, 2005. Sweet and Appelbaum, “A Meta-Analytic Review,” 2004.
100 D. Coates, Early childhood evaluation: A report to the Parkway Board of Education, Parkway School District, St.
Louis, MO, 1994. D. Coates, Memo on one-year update on Stanford scores of students. Early Childhood Evaluation
Study Group, December 26, 1996. D. Coates, Memo on one-year update on Stanford scores of students, Early
Childhood Evaluation Study Group, December 26, 1996. (As cited in Gomby, Home Visitation, 2005. Also cited in
Winter, M.M., 1999). “Parents as Teachers,” The Future of Children, vol. 9, no. 1 (Spring/Summer 1999), pp. 179-
189.)
101 Robert H. Bradley and Barbara Gilkey, “The impact of the Home Instructional Program for Preschool Youngsters
(HIPPY) on school performance in 3rd and 6th grades,” Early Education and Development, vol. 13, no. 3 (July 2002),
pp. 302-311. (As cited in Gomby, Home Visitation, 2005.)
102 Phyllis Levenstein et al., “Long-term impact of a verbal interaction program for at-risk toddlers: An exploratory
study of high school outcomes in a replication of the Mother-Child Home Program,” Journal of Applied Developmental
Psychology, vol. 19, no. 2 (1998), pp. 267-285. (As cited in Gomby, Home Visitation, 2005.)
103 Gomby, Home Visitation, 2005, p. 23.
104 David L. Olds, Charles R. Henderson, Jr., and Harriet Kitzman, “Does Prenatal and Infancy Nurse Home Visitation
Have Enduring Effects on Quality of Parental Caregiving and Child Health at 25 to 50 Months of Life?,” Pediatrics,
vol. 93, no. 1 (January 1994), p. 97. David L. Olds, Charles R. Henderson, Jr., and Harriet J. Kitzman et al., “Prenatal
and Infancy Home Visitation by Nurses: Recent Findings,” The Future of Children, vol. 9, no. 1 (Spring/Summer
1999), pp. 44, 52-55.
105 David L. Olds et al., “Effects of Nurse Home Visiting on Maternal and Child Functioning: Age-9 Follow-Up of a
Randomized Trial,” Pediatrics, vol. 120, no. 4 (October 2007), pp. p. e841-e842.
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group children with low-resource mothers had the lowest GPAs in the study.106 This same study
found that nurse-visited children had fewer failures in conduct during the first three years of
elementary school than control group peers.
Sixteen to twenty years after their participation in the randomized control study, high school drop
out rates for children who were assigned to participate in the Parent-Child Home Program were
found to be lower than those for children assigned to the control group. (This result was just
below statistical significance. Some outside researchers have described it as “marginally
significant,” while others have argued that the effect may have been due to chance rather than to
the program.107) At the time of their enrollment in the study, both PCHP participants and control
group children were considered “at-risk” based on the presence of certain child or family factors,
including parental unemployment, welfare receipt, low child IQ, single parenting, and/or poverty
status. The study’s researchers noted that the high school graduation rates for PCHP participants
were 30% higher than those of the control group that remained in the community and over 20%
higher than low-income students nationally.108
Examining Child Development Outcomes by Program Strategies
Controlled trials of Nurse Family Partnership programs have found mixed results with respect to
child development, sometimes concluding that these programs produced “few effects on
children’s development,”109 while at other times finding that home visited children of mothers
with “low psychologic resources” (i.e., low-functioning mothers, based on levels of intelligence,
mental health, and coping abilities) experienced home environments that were more “conducive
to early learning”110 than control group counterparts.
In an attempt to better parse effects, some studies have raised the issue of linking program quality
to program outcomes. For instance, the Nurse Family Partnership controlled trial in Denver
looked at differential outcomes for children based on whether or not the home visitor was a
registered nurse or a paraprofessional.111 In Denver studies, the paraprofessional program for low-
resource mothers was statistically linked to home environments that were more supportive of
early learning than the control group. However, the paraprofessional program had no statistically
significant effects on children’s language, executive functioning, or behavioral adaptation. By
contrast, the nurse program for low-resource mothers was linked to statistically significant,
positive effects on the home learning environment, as well as language development, executive
functioning, and behavioral adaptation during testing, compared to the control group.
106 Ibid.
107 Coalition for Evidence-Based Policy, Early Childhood Home Visitation Models: An Objective Summary of the
Evidence About Which Are Effective, April 2009, pp. 4-5, http://www.evidencebasedpolicy.org/docs/
OverviewOfEvidenceOnHomeVisitationModels409.pdf.
108 Phyllis Levenstein et al., “Long-term impact of a verbal interaction program for at-risk toddlers: An exploratory
study of high school outcomes in a replication of the Mother-Child Home Program,” Journal of Applied Developmental
Psychology, vol.19, no. 2 (1998), pp. 267-286.
109 David L. Olds, Charles R. Henderson, Jr., and Harriet J. Kitzman et al., “Prenatal and Infancy Home Visitation by
Nurses: Recent Findings,” The Future of Children, vol. 9, no. 1 (Spring/Summer 1999), pp. 44, 54-55.
110 David L. Olds et al., “Effects of Home Visits by Paraprofessionals and by Nurses: Age 4 Follow-Up Results of a
Randomized Trial,” Pediatrics, vol. 114, no. 6 (December 2004), pp. 1560-1568.
111 Ibid. See also Olds, David et al., “Home Visiting by Paraprofessionals and by Nurses: A Randomized, Controlled
Trial,” Pediatrics, vol. 110, no. 3 (September 2002), pp. 486-496.
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Some of the literature has suggested that child-focused strategies may be more successful than
parent-focused strategies in generating large benefits in a child’s cognitive development.112 A
meta-analysis conducted by Abt Associates in 2001 compares the effect of home visiting and
center-based early childhood education on cognitive development, and concludes that home
visiting services generate an effect size for cognitive development of 0.26, but programs with
early childhood education components generate effects almost twice as large (0.48).113 Others
have suggested that the center-based preschool education component accounted for 63% of the
variance in cognitive outcomes during the preschool years.114 In fact, there is a body of research
which suggests that to generate lasting cognitive and other developmental benefits for children,
home visiting should be linked with high-quality center-based child care and/or enrollment in a
high-quality preschool.115
Results from Early Head Start (which has center-based programs, home-based programs, and
programs that combine center-based and home-based services) research have found that,
compared to control groups, participation in center-based programs has consistently enhanced
cognitive development and, by age three, reduced negative aspects of children’s social-emotional
development.116 On the other hand, not all home-based Early Head Start programs have
demonstrated positive effects on cognitive development.117 In fact, one study reports that “home-
based programs had few significant impacts” compared to center-based programs and programs
combining center-based and home-based services.118 However, recent studies have found that full
implementation of HHS performance standards can affect program effectiveness.119 For instance,
HHS reports that when home-based Early Head Start programs fully implemented performance
standards, they demonstrated positive impacts on child cognitive development at the three-year
mark (suggesting that previous studies may have shown no effect because the performance
standards were not being rigorously implemented).120 Studies have found that some of the largest
gains from Early Head Start programs occur in the programs that combine center-based and
112 Jean Layzer, Barbara D. Goodson, and Lawrence Bernstein et al., National Evaluation of Family Support Programs:
Final Report Volume A: The Meta-Analysis, Abt Associates (prepared for the U.S. Department of Health and Human
Services), April 2001 (hereinafter Layzer, National Evaluation, 2001). Gomby, Home Visitation, 2005. Lynn A.
Karoly, M. Rebecca Kilburn, and Jill S. Cannon, Early Childhood Interventions: Proven Results, Future Promise,
RAND Corporation, 2005. Sweet and Appelbaum, “A Meta-Analytic Review,” 2004.
113 Layzer, National Evaluation, 2001.
114 Geoffrey Nelson et al., “A meta-analysis of longitudinal research on preschool prevention programs for children,”
Prevention & Treatment, vol. 6, no. 1 (December 2003).
115 Layzer, National Evaluation, 2001. Gomby, Home Visitation, 2005, pp. 24-25. Rand Corporation, Promising
Practices Network, “Early Head Start,” http://promisingpractices.net/program.asp?programid=135.
116 John M. Love, Ellen Eliason Kisker, and Christine M. Ross et al., Making a Difference in the Lives of Infants and
Toddlers and Their Families: The Impacts of Early Head Start, Mathematica Policy Research (prepared for the U.S.
Department of Health and Human Services), 2002 (revisions made January 2004), p. xxix (hereinafter Love et al.,
Making a Difference, 2004).
117 U.S. Department of Health and Human Services (HHS), Administration for Children and Families (ACF), Program
Models in Early Head Start, Early Head Start Research and Evaluation Project, April 2006, http://www.acf.hhs.gov/
programs/opre/ehs/ehs_resrch/reports/program_models/program_models.pdf.
118 Love et al., Making a Difference, 2004, p. 315.
119 Love et al., Making a Difference, 2004, pp. 303, 317.
120 U.S. Department of Health and Human Services (HHS), Administration for Children and Families (ACF), Early
Head Start Benefits for Children and Families, Early Head Start Research and Evaluation Project, April 2006,
http://www.acf.hhs.gov/programs/opre/ehs/ehs_resrch/reports/dissemination/research_briefs/
research_brief_overall.pdf.
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home-based services, with some effects in the 20-30% range.121 Moreover, combination programs
consistently demonstrated enhanced language development and aspects of social-emotional
development among children, as well as improved parenting behaviors and participation in self-
sufficiency oriented activities among parents.122 This held true, even at the three year mark, for
participating children and families.123
Findings in the Family/Parent Functioning Domain
Home visitation programs often seek to affect parenting behaviors to, among other things, reduce
child abuse and neglect. They may also seek to encourage family self-sufficiency through higher
educational attainment and increased work attachment.
Preventing Abuse and Neglect
Among other activities, providing parents with information about their children’s developmental
needs and abilities as well as communicating positive parenting skills are typical home visitation
activities intended to reduce the incidence of child maltreatment. The assumption that improved
parenting practices and attitudes may prevent child abuse and neglect is supported by research
suggesting that a lack of parenting knowledge may serve as one predictor of child
maltreatment.124
In randomized control trials of home visiting, researchers have been more likely to find
indications of changed parenting behaviors or attitudes—which suggest less harsh or abusive
parenting—than to find a significant difference in rates of reported or substantiated child abuse or
neglect. In a randomized control trial, the Nurse Family Partnership (NFP) showed reduced
substantiated child abuse and neglect reports in one site (Elmira), although this difference was not
shown as statistically significant until a number of years after the program ended. Any difference
in substantiated child abuse and neglect reports between treatment and control group families was
not tested at other NFP evaluation sites (Memphis and Denver).125 A randomized trial involving
parents who had already been reported for abuse and neglect found that home visited parents who
completed all three SafeCare training modules were less likely to recommit child maltreatment
than those in the control group.126 Other studies have shown no statistically significant results.
Implementers of Healthy Families America home visitation programs were encouraged early on
121 Love et al., Making a Difference, 2004, p. 286. U.S. Department of Health and Human Services (HHS),
Administration for Children and Families (ACF), Early Head Start Benefits for Children and Families, Early Head
Start Research and Evaluation Project, April 2006, http://www.acf.hhs.gov/programs/opre/ehs/ehs_resrch/reports/
dissemination/research_briefs/research_brief_overall.pdf.
122 Love et al., Making a Difference, 2004, p. 286. U.S. Department of Health and Human Services (HHS),
Administration for Children and Families (ACF), Early Head Start Benefits for Children and Families, Early Head
Start Research and Evaluation Project, April 2006, http://www.acf.hhs.gov/programs/opre/ehs/ehs_resrch/reports/
dissemination/research_briefs/research_brief_overall.pdf.
123 Love et al., Making a Difference, 2004, p. 286.
124 Lawrence M. Berger and Jeanne Brooks-Gunn, “Socioeconomic Status, Parenting Knowledge and Behaviors, and
Perceived Maltreatment of Young Low-Birth-Weight Children,” Social Service Review (June 2005), pp. 237-267.
125 Harriet L. MacMillian et al., “Interventions to Prevent Child Maltreatment and Associated Impairment,” The Lancet,
vol. 373 (January 17, 2009), pp. 250-266.
126 Michelle A. Johnson et al., Assessing Parent Education Programs for Families Involved with Child Welfare
Services: Evidence and Implications, Full Report (Supported by the Bay Area Social Services Consortioum and the
Zellerbach Family Foundation), March 2006, p. 21.
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by some quasi-experimental studies in Hawaii that showed much higher rates of abuse and
neglect in families where home visiting had not occurred (18%) compared to those where it had
occurred (1%).127 However, a subsequent randomized control study of the program did not find
any significant program effect with regard to rates of child maltreatment. 128 Similarly, some
evaluations of the Parents as Teachers model where the number of child maltreatment reports
were compared between control and treatment groups found no significant differences. In one
study of teenage mothers, however, those who received PAT services combined with case
management were less likely to be investigated for child maltreatment than were mothers in the
control group who received no services. This study found no statistically significant difference,
however, in this measure between teen mothers who received PAT-only services and those in the
control group.129
For a variety of reasons, it may be that the number of substantiated (or all reported) cases of child
maltreatment (studied at the individual level) is not a strong measure of program effectiveness
related to children’s experiences of abuse or neglect. The overall incidence of substantiated abuse
or neglect is relatively low across the population. Generally, this means that to show a
“statistically significant” effect, a fairly large number of participants must be included in a study.
If the number of participants is relatively small, even what appears to be a large difference in the
proportion of children abused among the control group and the treatment group may not be
statistically significant. Differing definitions of child abuse and neglect by state as well as varied
state policies for how investigators are to determine whether child abuse or neglect has occurred
also complicate any national or multisite effort that uses substantiated child abuse and neglect
reports to measure program effectiveness. Finally, families who are regularly visited by a nurse or
other family worker are subject to a high degree of surveillance and may thus be more likely to be
reported to the Child Protective Services (CPS) agency.130 Testing this common sense proposition,
a recent study in New York state found that mothers who participated in the Healthy Families
program and who admitted to having committed acts of serious abuse and neglect were nearly
twice as likely to have a CPS report than were control group parents who admitted to having
committed serious abuse or neglect.131
Improved Parenting Behaviors
Other measures have sometimes been used as proxies for the effect of a home visiting program on
child abuse or neglect. These include the number of health care or emergency department visits
that are tied to injuries or ingestions (see “Findings in the Maternal and Child Health Domain”),
and parental self reports of abusive actions, discipline strategies, or other relevant parenting
127 See discussion in Gomby, Home Visitation, 2005, p. 20. Gomby notes that some quasi-experimental studies
continue to produce findings like those early findings in Hawaii. Specifically she cites Oregon’s Healthy Family
program where rates of child maltreatment were 12 per 1000 for families served by Healthy Families program
compared to 22 per 1000 among non-served 0-two years olds in the same counties.
128 Anne Duggan, Elizabeth McFarland, and Loretta Fuddy et al., “Randomized Trial of Statewide Home Visiting
Program to Prevent Child Abuse: Impact in Preventing Child Abuse and Neglect,” Child Abuse & Neglect, vol. 28, no.
6 (June 2004), pp. 597-622.
129 Mary Wagner and Serena Clayton, “The Parents as Teachers Program: Results from Two Demonstrations,” The
Future of Children, vol. 9, no.1 (Spring/Summer 1999), pp. 91-115.
130 Kimberly S. Howard and Jeanne Brooks-Gunn, “The Role of Home Visiting Programs in Preventing Child Abuse
and Neglect,” Future of Children, vol. 19, no. 2 (in press).
131 RAND Corporation, Promising Practices Network, Programs that Work, “Healthy Families New York,”
http://www.promisingpractices.net/program.asp?programid=147#findings.
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practices. A randomized control study of the Healthy Families New York model found that home
visited mothers reported engaging in fewer abusive practices (i.e., fewer instances of neglect,
severe physical abuse, minor physical aggression, and psychological aggression against their
children) than did control group mothers. The researchers also noted that the positive effects were
stronger among only the subgroup of participants who were first-time mothers under age 19 and
enrolled in the prenatal period.132 An evaluation of SafeCare implementation found that parents
receiving the training were more likely to engage in positive parent behaviors.133
Effectiveness of home visitation in changing parenting behaviors and/or reducing child abuse or
neglect may be related to home visitors’ recognition of and response to additional family stress
factors and/or to provision of opportunities for peer support and interaction. In a randomized
control study of a statewide home visiting program in Hawaii (Hawaii Healthy Start, considered
the predecessor of the Healthy Families America program), researchers found a trend toward less
neglectful behavior from home visited mothers compared to those in the control group. Overall,
however, they concluded that the program did not prevent child abuse or promote use of
nonviolent parenting. Among the critical issues cited by the researchers as hindering program
effectiveness was the frequent failure of home visitors to identify and address family risk factors
(e.g., domestic violence, mental health needs).134 In a large meta-analysis of family support
programs, including many that used home visiting as the primary means of providing services and
others that did not, researchers found that efforts to improve parenting behaviors, attitudes, and
practices were most successful when they specifically focused on developing parents’ skills as
effective adults—their self-confidence, self-empowerment, family management, and parenting—
and included opportunities for peer support (e.g., parent mutual support groups meeting outside
the home).135 The Parents as Teachers home visiting model includes, as a core part of its program,
parent group meetings and other opportunities for parents to share information with and learn
from each other, and the HIPPY model also includes regular group meetings.136
Family Self-Sufficiency
Many home visitation programs seek to improve family self-sufficiency over the longer term by
ensuring increased educational attainment and labor force participation among visited families. A
study comparing at-risk PAT families (40) to a comparison group in Binghamton, NY, found that
welfare dependence doubled for both groups in the year following the child’s birth, but that
between the first and second birthday “marginally significant differences” emerged, with welfare
dependence declining in the visited group and increasing among the control group.137 In the initial
132 Kimberly DuMont, Susan Mitchell-Herzfeld, and Rose Greene et al., “Healthy Families New York (HFNY)
Randomized Trial: Effects on Early Child Abuse and Neglect,” Child Abuse and Neglect, vol. 32 (2008), p. 295-315.
133 Ronit M. Gershater-Molko, John R. Lutzker, and David Weeks, “Project SafeCare: Improving Health, Safety and
Parenting Skills in Families Reported for, and At-Risk for Child Maltreatment,” Journal of Family Violence, vol. 18,
no. 6 (December 2003), p. 377-386.
134 Duggan et al., “Impact in reducing parental risk factors,” 2004, pp. 625-645.
135 Layzer, National Evaluation, 2001. With regard to overall family functioning, the evaluators noted that family
support programs with a specific focus on prevention of child abuse and neglect tended to be the same programs that
provided parents with peer support activities, and that because of the inter-relationship among these factors they were
not able to determine which of these program characteristics had the greatest positive effect on family functioning
outcomes.
136 Fostering parent leadership through mutual support groups and other avenues is a key object of Community-Based
grants to Prevent Child Abuse and Neglect (Title II of CAPTA).
137 RAND Corporation, Promising Practices Network, Programs That Work, “Parents as Teachers,”
(continued...)
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NFP test in Elmira, NY, nurse-visited first-time mothers had greater labor force participation than
did control group mothers two years after the evaluation ended (i.e., at child’s fourth birthday).
Thirteen years after the Elmira evaluation ended (by the child’s 15th birthday), nurse-visited
mothers who were unmarried and from low socioeconomic backgrounds at the time of program
enrollment had spent less time receiving public aid (including cash aid and Food Stamps) than
comparable mothers in the control group who did not receive nurse visits.138 Similar findings
related to public assistance use were found among first-time at-risk mothers both four years and
seven years after an NFP trial in Memphis ended: nurse-visited mothers spent less time receiving
public assistance than did control group mothers who were not visited.139 In a third NFP trial, this
one in Denver, comparisons were made between low-income mothers who received home visits
by nurses, those who receive home visits by paraprofessionals, and those who received no visits.
Two years after the trial ended, paraprofessional-visited mothers worked more than mothers in the
control group. There was no significant difference between nurse-visited mothers and control
group mothers with regard to workforce participation. Finally, neither nurse-visited nor
paraprofessional-visited mothers showed statistically significant outcomes that were different
from control group mothers with regard to their own educational achievement or use of welfare
two years after the trial ended.140
Recent Administration and Congressional Proposals
to Support Home Visiting
The President’s FY2010 budget request includes a proposal to provide mandatory funding to
states for home visitation programs, and the FY2010 budget resolution (S.Con.Res. 13) supports
increased federal funding for these programs provided this can be done in a “deficit neutral”
manner. A number of legislative proposals to provide more support for home visitation programs
have been offered, and both the pending health care reform proposal (H.R. 3200) in the House
and the health care legislation reported by the Senate Finance Committee (S. 1796) include
funding for grants to states to support the expansion of home visiting to families with young
children and those expecting children.
Obama Administration’s FY2010 Budget Proposal
As part of its FY2010 budget request the Obama Administration proposes a new capped
entitlement program to support formula grants to states, territories, and tribes for the
establishment and expansion of “evidence-based” home visitation programs for low-income
(...continued)
http://www.promisingpractices.net/program.asp?programid=88.
138 David L. Olds et al., “Long-term Effects of Home Visitation on Maternal Life Course and Child Abuse and Neglect:
Fifteen-year Follow-Up of a Randomized Trial,” Journal of American Medical Association, vol. 278, no. 8 (2007), pp.
637-643.
139 David L. Olds et al., “Effects of Nurse Home Visiting on Maternal and Child Functioning: Age-9 Follow-up of a
Randomized Trial,” Pediatrics, vol. 120, no. 4 (October 2007), pp. e832-e843. David L. Olds, et. al., “Effects of Nurse
Home Visiting on Maternal Life Course and Child Development: Age-6 Follow-up Results of a Randomized Trial,”
Pediatrics, vol. 114, no. 6 (December 2004), pp. 1550-1559.
140 David L. Olds et al., “Effects of Home Visits by Paraprofessionals and by Nurses: Age 4: Follow-Up Results of a
Randomized Trial,” Pediatrics, vol. 114, no. 6 (December 2004), pp. 1560-1568.
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mothers and pregnant women. The program is expected to “create long-term positive impacts for
children and their families, as well as generate long-term positive impacts for society as a
whole.”141 Outcomes the Administration cites that may be achieved by home visitation include
reductions in child abuse and neglect, improvements in children’s health and development and
their readiness for school, and improvements in the ability of parents to support children’s
optimal cognitive, language, social-emotional, and physical development. It notes that one model
of home visitation, which used nurses to visit low-income first-time mothers, was found to reduce
Medicaid costs in several randomized control trials. Accordingly the Administration assumed that
expanding proven effective home visitation programs would result in savings to the Medicaid
program (via reductions in preterm births, emergency room use, and subsequent births) totaling
$77 million in the first five years and $664 million over the entire 10 years.142
Mandatory funding for the newly proposed home visitation program is proposed at $124 million
in budget authority ($87 million in “outlays”143) in FY2010, rising each year to $790 million in
budget authority ($710 million in outlays) by year five of the program (FY2014) and to $1.837
billion in budget authority ($1.753 billion in outlays) in year ten (FY2019).144 This funding is
expected to allow home visiting services to 50,000 families in the initial year of the program,
rising to 450,000 new families by FY2019.145
Under the Administration’s proposal, states would be expected to provide some matching funds to
receive federal home visitation grants. Further, the Administration would give priority to funding
for models “that have been rigorously evaluated and shown to have positive effects on critical
outcomes for families and children.” Accordingly, states, territories, and tribes seeking grants
under the proposed home visitation program would be required to submit a plan describing,
among other things, the program model they will follow, evidence for the effectiveness of the
program model, and how the state will ensure that the proven program model is adhered to
(model fidelity). Funding related to programs with strong research evidence demonstrating their
effectiveness would include technical assistance, monitoring, and evaluation to ensure fidelity of
the model and for “evaluating effectiveness of these models as conditions change over time.” The
Administration also anticipates that additional funds will support “promising programs” such as
those based on some research evidence and those that are adaptations of previously evaluated
programs. Funding for these programs would also include technical assistance, monitoring, and
evaluation that focuses on developing these promising models and on “rigorous (random
assignment) evaluations of effectiveness.” Finally, the Administration proposes that no less than
5% of the program’s overall funding be reserved for research, evaluation, training, technical
assistance, monitoring, and administration.146
141 U.S. Department of Health and Human Services, Administration for Children and Families (ACF), FY2010
Justification of Estimates for the Appropriations Committees (hereinafter FY2010 ACF budget justification), p. 267.
142 Ibid. U.S. Department of Health and Human Services (HHS), Fiscal Year 2010 Budget in Brief, p. 84.
143 Budget authority is the amount of money Congress allows a federal agency to commit to spend (i.e., the legal
authority for an agency to incur financial obligations that will result in immediate or future outlays involving federal
funds). Outlays are the amount of money that actually flows out of the federal treasury in a given year (i.e., a payment
by the government in fulfillment of an obligation). Outlays during a fiscal year may be for payment of obligations
incurred in the same year or in prior years. In the example above, Congress is authorizing $124 million to be made
available for obligation in FY2010, but is estimating that only $87 million of the $124 million will actually be outlaid
(or expended) in that fiscal year.
144 Office of Management and Budget, Updated Summary Tables, May 2009, p. 24 and communications with ACF.
145 FY2010 ACF budget justification, p. 268.
146 Ibid, pp. 267-268.
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Based on its inclusion in the Administration for Children and Families (ACF) budget
justifications, this HHS agency is expected to administer the program. At the same time, the
FY2010 budget request notes an effort to coordinate planning for the proposal across HHS
agencies to ensure the most effective program structure. It further notes that “a coordinated
strategy” involving the Centers for Disease Control and Prevention (CDC), the Centers for
Medicare and Medicaid Services (CMS), the Health Resources and Services Administration
(HRSA), and ACF will “enable HHS to respond to varying approaches that States may wish to
use to implement this initiative.”147
FY2010 Budget Resolution
In late April 2009, the House and Senate approved a conference agreement on the FY2010 budget
resolution (S.Con.Res. 13), which reconciles separate FY2010 budget resolution proposals passed
earlier that month by the House (H.Con.Res. 85) and Senate (S.Con.Res. 13). The FY2010 budget
resolution is designed to set federal funding priorities across all purposes for the upcoming fiscal
year. According to the conference report on the budget resolution (H.Rept. 111-89), the agreement
includes a “deficit neutral reserve fund” for establishing or expanding home visitation programs.
Proposed Grants to States for Home Visitation in Health Care
Legislation
Health care reform bills under consideration in the House and in the Senate would provide funds
for grants to states to support expanded delivery of evidence-based home visitation services to
families with young children and those expecting children. In the House, America’s Affordable
Health Choices Act of 2009 (H.R. 3200), as ordered reported in mid-July,148 would appropriate
$750 million over five years (FY2010-FY2014) for this purpose. On the Senate side, America’s
Healthy Futures Act (S. 1796), as reported by the Senate Finance Committee in mid-October
(S.Rept. 111-89), would appropriate $1.5 billion over five years (FY2010-FY2014).149 Separately,
H.R. 3200, as ordered reported, would amend Medicaid to clearly permit states to claim federal
reimbursement for “nurse home visitation services” provided to certain Medicaid eligible
individuals. S. 1796, as reported by the Senate Finance Committee, does not include a
comparable amendment to Medicaid.
Congressional interest in greater support for early childhood home visitation programs predates
the pending health care reform legislation. Both the Early Support for Families Act (H.R. 2667)
and the Evidence-Based Home Visitation Act (S. 1267) were introduced in June 2009. The home
147 U.S. Department of Health and Human Services (HHS), Fiscal Year 2010 Budget in Brief, p. 84.
148 Discussion of provisions in H.R. 3200 throughout this report refer to Sections 1713 and 1904 of that bill as included
in “Amendment in the Nature of a Substitute,” posted on the House Energy and Commerce Committee website at
“http://energycommerce.house.gov/Press_111/20090715/health_amendment.pdf . The text of the bill spans multiple
committee jurisdictions. Provisions in Section 1904 (related to grants to states for home visiting) were ordered reported
by the House Ways and Means Committee. Provisions in Section 1713 (related to nurse home visitation services under
Medicaid) were ordered reported by the House Energy and Commerce Committee.
149 Discussion of provisions in S. 1796 throughout this report refers to Section 1801 of the bill as included in
“Legislative Language of American’s Healthy Futures Act” posted on the Senate Finance Committee website at
http://finance.senate.gov/sitepages/leg/LEG%202009/101909%20America's%20Healthy%20Furture%20Act%202009
%20Leg.pdf.
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visitation provisions included in Section 1904 of H.R. 3200, as ordered reported in July, are most
similar to those included in H.R. 2667. In turn, H.R. 2667 and S. 1796, as reported by the Senate
Finance Committee, appear to have drawn some inspiration from the Education Begins at Home
Act (S. 244 and H.R. 2205), which has been under congressional consideration for a number of
years. An initial version of the Education Begins at Home Act was introduced in the Senate
during the 107th Congress and in the House in the 108th Congress. Further, during the 110th
Congress, the House Education and Labor Committee marked up and reported an amended
version of the bill (H.Rept. 110-818), although the full House did not subsequently act on it
before that Congress ended.150 Finally, although the Healthy Families and Children Act (S.
1052/H.R. 3024 in the 110th Congress) has not been reintroduced in this Congress, a central
concept of that bill—defining “medical assistance” under the Medicaid program to include certain
nurse home visitation services—is included in the House health care reform proposal (Section
1713 of H.R. 3200, as ordered reported).
The following section discusses the home visitation provisions included in H.R. 3200, as ordered
reported, and S. 1796, as reported by the Senate Finance Committee.
Purposes and Funding Proposed for Home Visitation
Both H.R. 3200 and S. 1796 would provide funds to support home visitation programs for
families with young children or infants and for those expecting children.
H.R. 3200 would amend Title IV-B of the Social Security Act, which currently authorizes the
Stephanie Tubbs Jones Child Welfare Services and the Promoting Safe and Stable Families
program, to establish Home Visitation Programs for Families with Young Children and Families
Expecting Children. The purpose of this support would be to improve the well-being, health, and
development of children. Funds would be made available to eligible states, territories, and tribes
that applied. H.R. 3200 would appropriate five years of funding as follows: $50 million for
FY2010, $100 million for FY2011, $150 million for FY2012, $200 million for FY2012, and $250
million for FY2014.
S. 1796 would amend Title V of the Social Security Act, which currently authorizes the Maternal
and Child Health Services block grant, to establish Maternal, Infant and Early Childhood
Visitation programs. The overall purposes of the amendment include improving outcomes for
families in “at-risk” communities through provision of comprehensive services. Grants for home
visitation programs would be provided specifically to promote improvements in maternal and
prenatal health, infant and child health, child development, parenting related to child development
outcomes, and school readiness, as well as the socioeconomic status of pregnant women, men
expecting to be fathers, and parents or other primary caregivers of young children. States,
territories, and tribal entities that successfully applied for these funds would be awarded funds to
support early childhood home visitation programs. (In addition, HHS would be permitted to
provide funds to other eligible nonprofit organizations in any given state if, as of FY2012, that
state had not applied for and been awarded a home visitation grant.) S. 1796 would appropriate
funds for these grants for five years as follows: $100 million for FY2010; $250 million for
FY2011; $350 million for FY2012; $400 million for FY2012; and $400 million for FY2014.
150 The current House version of the Education Begins at Home Act (H.R. 2205) largely reflects that reported version
of the bill while the Senate version (S. 244) remains closer to its 107th Congress origins.
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Home Visitation Program Criteria
Both the House and Senate proposals would require that these new federal funds be used to
primarily support home visitation services that follow a clearly designed program model that has
demonstrated positive effects for families with young children and those expecting children.
However, they would also permit states to use at least some of the funds for promising program
models with less established records of success.
H.R. 3200 stipulates that federal funds are to be used to support programs that “adhere to clear
evidence-based models of home visitation and that have demonstrated positive effects on
important program-determined child and parenting outcomes.” At the same time, states would be
permitted to use a declining share of their federal home visiting funds to support programs that
“do not adhere to a model of home visitation with the strongest evidence.” For FY2010, states
would be permitted to spend as much as 60% of their funds on programs that did not have the
“strongest evidence,” but this amount would decrease by 5 percentage points each year, until it
reached 40% for FY2014.
S. 1796 would permit states to spend up to 25% of their funds on home visitation program models
that follow a new approach to achieving a range of improved child and family outcomes,
provided the model was developed or identified by a national organization or institution of higher
education and will be rigorously evaluated. The remaining 75% of the funding received, however,
would need to be used in support of home visitation services that 1) follow a clear and consistent
model that has been in existence for at least three years; 2) are research-based, grounded in
relevant empirically based knowledge, and linked to program-determined outcomes; 3) are
associated with a national organization or institution of higher education that has comprehensive
home visitation program standards to ensure high-quality service delivery and continuous
program quality improvement; and 4) demonstrated significant positive outcomes on a range of
specific child and family outcomes when evaluated in well-designed research studies (see
“Outcomes of Interest,” below). Finally, the rigorous evaluation of these programs must have
been conducted using a quasi-experimental research design or a randomized control research
design. (Further, if the evaluation used a random control research design, the results must indicate
“sustained” positive outcomes and must have been published in a peer-reviewed journal.)
H.R. 3200 and S. 1796 would both additionally require that the home visitation programs
supported with federal funds employ well-trained staff and provide ongoing training, maintain
high-quality supervision, monitor fidelity of program implementation to the program model being
used, and establish appropriate linkages and referrals to other community resources.
H.R. 3200 would further require that any home visitation program model used provide parents
with 1) knowledge of age-appropriate child development in cognitive, language, social, emotional
and motor domains, along with expectations of age-appropriate child behavior; 2) skills for
interacting with children to enhance age-appropriate development and for being able to recognize
and seek help related to developmental delays or any health, social, or behavioral issues; 3)
knowledge of health and wellness issues for children and parents; 4) coaching on modeling of
parenting practices; and 5) activities designed to help parents become full partners in the
education of their children. Alternatively, S. 1796 would require that any program model used be
designed to result in improvements in relevant outcome areas (as identified by the state in an
individualized family assessment for participants). Improvements in any of the following areas
may be determined to be relevant: prenatal, maternal, newborn, and child health; child
development (including prevention of injuries and maltreatment and improved cognitive,
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language, social-emotional, and physical development), parenting skills, school readiness, and
child academic achievement; reductions in crime or domestic violence; family economic self-
sufficiency; and coordination of resources and supports for families.
Outcomes of Interest
S. 1796 would require each state to establish benchmarks that would be used to measure changes
in outcomes related to maternal and newborn health; child injuries and use of emergency rooms;
school readiness and achievement; crime or domestic violence; family economic self-sufficiency;
and coordination of community resources and supports. States must demonstrate improvements in
at least four of these areas by the end of their third year of grant funding (and submit this
information in a report to HHS) and they must submit a final report on any improvements in these
outcome areas no later than December 31, 2014. Any state that does not show improvement in at
least four of the outcome areas by the end of the third year must develop and implement, subject
to the approval of HHS, a corrective action plan to improve outcomes in each of the specified
areas. The plan must include provisions for HHS to monitor its implementation, and HHS would
be required to provide or otherwise support technical assistance to any state needing to implement
such a plan. Finally, if after a period of time (determined by HHS) the state does not show
improvement in any of its benchmarks, or it has not submitted a report describing changes in
outcomes as measured against those benchmarks, HHS must terminate funding to the state for
home visitation.
H.R. 3200 would require states to use federal funds under the new home visitation program in
support of programs that have demonstrated positive effects on “important-program-determined
child and parenting outcomes, such as reducing abuse and neglect and improving child health and
development.” It does not include provisions comparable to those in S. 1796 related to
establishing benchmarks to measure improvements in specified outcome areas.
Additional Requirements for Receipt of Funds
Statewide Needs Assessment: Before states received federal support for home visitation programs,
both the House and Senate proposals would require a statewide needs assessment. The assessment
would look at the quality and capacity of home visitation programs currently operating in the
state, the number and types of families receiving services, and any gaps in provision of the
services. States would also need to identify high-risk or high-need communities.
H.R. 3200 would require states to report the results of this assessment in their application for
home visitation funds. S. 1796 would require states, no later than six months after enactment of
the bill, to make this assessment as a condition of receiving funds under the Maternal and Child
Health (MCH) block grant for FY2011. Further, S. 1796 would require states to coordinate this
needs assessment with several other relevant statewide assessments that are now required under
the MCH block grant, the Head Start Act, and the Community-Based Grants to Prevent Child
Abuse and Neglect program (Title II of the Child Abuse Prevention and Treatment Act). States
would be required to submit the results of this unique statewide needs assessment to HHS,
including a description of how they intended to address the needs identified—especially in high-
risk communities—and which might include applying to receive a federal grant to support early
childhood home visitation services. Finally, S. 1796 would require states to explain in any
application for early childhood home visitation services how the populations to be served and the
program model(s) to be used are consistent with the needs assessment.
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Grant Application: In order to receive grant funds, both H.R. 3200 and S. 1796 would require
states to submit an application to HHS. The specific application requirements vary somewhat, but
under both proposals a state would need to include a description of the home visitation
program(s) to be funded, identify the populations to be served, and include an assurance that the
state will give priority to serving families in high-need or high-risk communities, including
communities with high concentrations of low-income families and those with high incidence of
child maltreatment and/or family involvement with child welfare. In addition, both bills would
require states to give assurance that they would cooperate with any research or evaluation
conducted (or supported by HHS) under this program and provide annual reports to HHS and any
other information required by HHS. H.R. 3200 would additionally require states to give assurance
in their grant application that they will set aside no less than 5% of the federal funds they receive
for training and technical assistance to the home visitation programs receiving federal funding.
No comparable requirement of states is included in S. 1796.
Maintenance of Effort
S. 1796 would not require states to maintain a specified level of funding for home visitation but
would stipulate that any funds provided under the new grant program be used to “supplement, and
not supplant, funds from other sources for early childhood home visitation programs or
initiatives.” H.R. 3200 would require states to maintain funding for home visitation programs as
follows: Beginning with FY2011, a state would not be eligible for the new home visitation
funding unless HHS determined that the state’s total non-federal (state and local) spending for
home visitation programs serving families with young children and those expecting children was
no less in the immediately preceding fiscal year than in the second preceding fiscal year. (For
example, to receive FY2011 funds, HHS would need to find that the state’s total non-federal
spending for home visiting services in FY2010 was no less than it had been in FY2009; for a state
to receive FY2012 funds, HHS must find that the state’s home visitation spending in FY2011 was
no less than it had been in FY2010, and so on.)
State Match and Distribution
Matching Funds: S. 1796 would not require a state to provide matching funds under the early
childhood home visitation program. By contrast, to receive their full allotment of home visitation
funding, H.R. 3200 would require states (in FY2010) to provide no less than 15% of the total
federal and state dollars spent for home visitation programs serving families with young children
and families expecting children. The required share of state spending under H.R. 3200 would rise
to 20% in FY2011 and 25% in FY2012, where it would remain for every succeeding year in
which the program is funded. (Under H.R. 3200, these state matching dollars might also be
counted toward the state’s required maintenance of effort.)
Set Asides: Both bills would appropriate funds for home visitation and would require that before
their distribution to eligible states and territories, funds be set aside for certain purposes. H.R.
3200 would require HHS to annually set aside 5% of the home visitation funds appropriated for
program-related training, technical assistance, and evaluation, and, after making this reservation,
3% of the appropriated funds for grants to tribes. S. 1796 would require HHS to set aside 3% of
the annual appropriated amount for research, technical assistance, and evaluation, and 3% for
grants to tribal entities.
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Distribution: H.R. 3200 would allocate funds to each eligible state (including territories) based on
the number of children in each state who live in families with incomes that do not exceed 200%
of the poverty line compared to the number of all children in those states and territories who live
in families with incomes that do not exceed 200% of the poverty line. A state that fully meets the
match requirements would be eligible to receive its full allotment. (Funds set aside for tribes each
year would be distributed in a similar manner, with an eligible tribe’s share of the total tribal
funding based on its relative share of the children living in families with incomes that do not
exceed 200% of the poverty line among all eligible tribes.)
S. 1796 would require HHS to make early childhood home visitation grants to eligible applicants
(including states, territories, tribal entities, and, in certain situations, other nonprofit
organizations) and would permit HHS to determine the duration of the grants. However, it does
not describe how the funds are to be distributed.
Evaluation and Research, Other Reports to Congress, and Technical Assistance
Evaluation and Research: Both H.R. 3200 and S. 1796 would require HHS to provide for, and
report to Congress on, an evaluation of the effectiveness of the federally supported home
visitation programs. S. 1796 would separately require HHS to conduct (via grants, cooperative
agreements, or contracts) a continuous program of research and evaluation activities to increase
knowledge about the implementation and effectiveness of home visiting programs.
Other Reports to Congress: H.R. 3200 would also require HHS to submit annual reports to
Congress on activities carried out with the grant funds. S. 1796 would not require HHS to report
to Congress annually on activities under the program, however, it would require that a report on
the program, including recommendation for any legislative or administrative actions determined
appropriate, be made to Congress no later than December 31, 2015.
Technical Assistance: S. 1796 would require HHS to provide (directly or otherwise) technical
assistance to states that fail to demonstrate improved outcomes in at least four of the areas
measured and that are consequently required to develop corrective action plans (see “Outcomes
of Interest”). The bill would further require HHS to establish an advisory panel to make
recommendations regarding provisions of this technical assistance. H.R. 3200 would require HHS
to provide technical assistance and training to states, including dissemination of best practices in
early childhood home visitation.
Program Administration
Neither H.R. 3200 nor S. 1796 specify any particular agency that is expected to administer the
funds at the state level. H.R. 3200 also does not specify any specific federal agency within HHS
that would be expected to administer the program. However, as noted above, it would add this
new program to the Child and Family Services section of the Social Security Act (Title IV-B), and
the programs in that part of the law are currently administered by the Administration for Children
and Families (ACF) within HHS. Also as noted earlier, S. 1796, as reported by the Senate Finance
Committee, amends Maternal and Child Health Services authorized in the Social Security Act
(Title V), and programs and activities in this part of the law are now administered by the Health
Resources and Services Administration (HRSA), also within HHS. S. 1796 would require HRSA
and ACF to collaborate in all aspects of the federal administration of the program and would also
stipulate that in doing this they consult with additional relevant federal agencies.
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Proposed Nurse Home Visitation Services Under Medicaid
Section 1713 of H.R. 3200, as ordered reported by the House Energy and Commerce Committee,
would create a new optional Medicaid benefit called “nurse home visitation services,” and would
permit states to seek federal reimbursement at their Federal Medical Assistance Percentage (or
FMAP) rate (which may range from 50%-83%)151 for providing these services. The bill would
define “nurse home visitation services” as home visits by trained nurses to families with a first-
time pregnant woman or a child (under two years of age) and who are otherwise eligible for
Medicaid, but only if HHS determines that there is evidence that these services are effective in
one or more of the following areas: 1) improving maternal or child health and pregnancy
outcomes or increasing birth intervals between pregnancies; 2) reducing the incidence of child
abuse, neglect, and injury, improving family stability (including reductions in domestic violence),
or reducing maternal and child involvement in the criminal justice system; and 3) increased
economic self-sufficiency, employment advancement, school readiness and other educational
achievement, or reducing dependence on public assistance.
Federal reimbursement for this new optional Medicaid service would be effective January 1,
2010. H.R. 3200 would stipulate that creation of this new optional Medicaid benefit must not be
construed to prevent states from continuing to claim federal reimbursement for home visitation
services under currently authorized Medicaid care coordination and case management activities
(as an administrative activity or a benefit).
Hearing on Proposals to Support Early Childhood Home Visitation
On June 9, 2009, the Subcommittee on Income Security and Family Support of the House Ways
and Means Committee held a hearing on proposals to provide funds to states for early childhood
home visitation programs. Witnesses included researchers, an administrator of state funding for
home visitation programs, a former participant and current home visitor, and a nurse
consultant.152
The witnesses generally supported broader implementation of early childhood home visitation
programs that are informed by evidence on efficacy. Most witnesses appeared to support
availability of home visitation services to any family, without regard to any specific demographic
or family risk factors, although one witness clearly favored providing services to low-income
mothers. At the same time, in responding to a question regarding which families they would
target if limited funds were available, at least one witness cautioned against using demographic
markers to select families, but suggested the importance of engaging families early, perhaps
during pregnancy (via prenatal clinics or obstetric offices) or at birth (via hospital). Another
witness stressed first-time young mothers as an important group, and one where research to date
has shown the greatest level of successful outcomes.
151 The reimbursement rate would be linked to a state’s Federal Medical Assistance Percentage (or FMAP), which
varies based on the state’s per capita income. By statute, it may range from a low of 50% (in states with high per capita
income) to a high of 83% (in states with low per capita income). The American Recovery and Reinvestment Act
temporarily (from October 1, 2009, through December 31, 2010) raises each state’s FMAP. For more information, see
CRS Report R40223, American Recovery and Reinvestment Act of 2009 (ARRA, P.L. 111-5): Title V, Medicaid
Provisions, coordinated by Cliff Binder.
152 To view hearing testimony, go to http://waysandmeans.house.gov/hearings.asp?formmode=detail&hearing=682.
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In their written testimony, at least two of the witnesses, both researchers, cautioned that supported
programs—regardless of any prior demonstrated level of evidence—must have certain attributes
to succeed. Both mentioned the need for (1) clearly linking program activities to expected
program goals, (2) providing services (engaging family) with sufficient frequency and for a
sufficient length of time to have an impact, and (3) employing well-trained home visitors whose
work is evaluated/supervised on an ongoing basis.153 Other factors given as important to program
success included solid organizational capacity and linkages to other community resources and
supports.154
153 Written testimony of Deborah Daro, June 9, 2009, p. 5. Written testimony of Jeanne Brooks-Gunn, June 9, 2009, p.
3. In addition to well-trained staff, Brooks-Gunn suggested the importance of well-educated staff (whether nurses,
social workers, or some other professional).
154 Written testimony of Deborah Daro, June 9, 2009, p. 5.
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Appendix A. Selected Federal Programs That
Provide or Support Home Visitation
As discussed in the section on “Existing Federal, State, and Local Funding Streams for Home
Visiting,” a number of federal programs are already being used to support early childhood home
visitation efforts. Federal statute for these programs may require some amount of home-based
services (e.g., Even Start), explicitly permit home visiting as a possible activity (e.g., Maternal
and Child Health Block Grant), or allow home visiting under broad authorities or program goals
(e.g., Medicaid). Selected programs, arranged alphabetically, are briefly described below.
Community-Based Grants for the Prevention of Child Abuse and
Neglect (CBCAP)
Title II of the Child Abuse Prevention and Treatment Act (CAPTA) authorizes grants to support
community-based services for the prevention of child abuse and neglect. CBCAP grants are
distributed by formula to a lead entity in all states (which may be a public agency, a quasi-public
entity, or a nonprofit private organization). The lead entity is charged with developing a
continuum of community-based services for children and families that are designed to strengthen
and support families to prevent child abuse and neglect. Core family resource and support
services to be provided by community-based programs include voluntary home visiting services,
parent education, community and social services referrals, and respite care services, among
others. In their FY2007 program summaries, the majority of state CBCAP contacts indicated
explicit support of home visiting services. In FY2009, the CBCAP program received funding of
approximately $42 million (P.L. 111-8). CBCAP is administered by the Office of Child Abuse and
Neglect within the Children’s Bureau of the Administration for Children and Families at HHS.155
Early Head Start
Early Head Start is a federally funded community-based program for low-income expectant
parents and families with infants and toddlers that seeks to (1) promote healthy prenatal
outcomes; (2) enhance the development of infants and toddlers; and (3) promote healthy family
functioning. Nationwide, there are more than 650 Early Head Start programs providing child
development and family support services, serving approximately 62,000 children under the age of
three annually.156 Grantees select an Early Head Start service delivery option (typically center-
based, home-based, or a combination) to meet the needs of the children and families in their
communities. In 2006, about half (51%) of Early Head Start slots were center-based, while
41% were in home-based programs.157 Children and families enrolled in center-based programs
155 Child Abuse Prevention and Treatment Act, Title II. FY2007 CBCAP program summaries at
http://www.friendsnrc.org/resources/07sum.htm. See also certain CBCAP requirements in Table 3 of CRS Report
RL31242, Child Welfare: Federal Program Requirements for States, by Emilie Stoltzfus.
156 See Head Start Program Fact Sheets at http://eclkc.ohs.acf.hhs.gov/hslc/About%20Head%20Start/
headstart_factsheet.html.
157 Elizabeth Hoffman and Danielle Ewen, Supporting Families, Nurturing Young Children: Early Head Start
Programs in 2006, CLASP Policy Brief No. 9, December 2007, pp. 2-5, http://www.clasp.org/publications/
ehs_pir_2006.pdf.
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receive comprehensive child development services in a center-based setting, supplemented with
limited home visits by the child’s teacher and other Early Head Start staff (a minimum of two
home visits a year to each family). In home-based programs, children and their families are
supported through weekly home visits of at least 90 minutes and bimonthly group socialization
experiences. Combination programs provide a blend of center class sessions and 90-minute home
visits (regulations specify acceptable combinations of minimum numbers of class sessions and
corresponding home visits).158
Home visits are conducted by professionals who receive training in child development, family
development, and community building. In FY2008, the majority of Early Head Start teachers
(54%) and home visitors (66%) held a degree in early childhood education (or a related field).159
Legislation that reauthorized the program in 2007 (P.L. 110-134) required HHS to develop
standards for Early Head Start home visitors related to staff training and qualifications, as well as
to conduct of home visits.160
In FY2009, HHS estimated that Early Head Start programs received over $675 million out of the
total appropriation provided for Head Start, and additional funds (approximately $619 for
FY2009) were provided via the American Recovery and Reinvestment Act (P.L. 111-5).161 The
program is administered by the Office of Head Start within the Administration for Children and
Families (ACF) at HHS.
Even Start
Even Start programs are authorized by ESEA Title I, Part B, Subpart 3, and are intended to
integrate early childhood education, adult basic education, and parenting skills education into a
unified family literacy program.162 Funds are distributed to all states and must be subgranted to
local education agencies working in collaboration with community based organizations. Even
Start programs generally serve children aged zero to seven and their parents. Services must
include home-based instruction, adult literacy instruction, early childhood education, instruction
to help parents support their child’s education, participant recruitment, screening of parents, and
staff training. An assumption underlying Even Start is that children whose parents have low
158 See relevant regulations at 45 CFR 1306.
159 Statistics are based on 2007-2008 Program Information Reports (PIR) data. Note that “degree” encompasses
associate, baccalaureate, and advanced degrees.
160 The reauthorized Head Start Act specifies that the standards for training, qualifications, and the conduct of home
visits shall include content related to (1) structured, child-focused home visiting that promotes parents’ ability to
support the child’s cognitive, social, emotional, and physical development; (2) effective strengths-based parent
education, including methods to encourage parents as their child’s first teachers; (3) early childhood development with
respect to children from birth through age three; (4) methods to help parents promote emergent literacy in their children
from birth through age three, including use of research-based strategies to support the development of literacy and
language skills for children who are limited English proficient; (5) ascertaining what health and developmental services
the family receives and working with providers of these services to eliminate gaps in service by offering annual health,
vision, hearing, and developmental screening for children from birth to entry into kindergarten, when needed; (6)
strategies for helping families coping with crisis; and (7) the relationship of health and well-being of pregnant women
to prenatal and early child development.
161 In total, P.L. 111-5 appropriated $1.1 billion specifically for the expansion of Early Head Start and HHS expected to
award approximately $619 million of these expansion funds in FY2009. For more information, see CRS Report
R40211, Human Services Provisions of the American Recovery and Reinvestment Act, by Gene Falk et al.
162 For more information, see CRS Report RL30448, Even Start Family Literacy Programs: An Overview, by Gail
McCallion, and CRS Report CRS Report RL33071, Even Start: Funding Controversy, by Gail McCallion.
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literacy or basic education levels are more likely to be educationally successful if, in addition to
receiving early childhood instruction themselves, their parents receive educational services plus
instruction in how to help their children learn. The program is administered by the Office of
Elementary and Secondary Education, within the Department of Education. It was funded in
FY2009 at $66 million. President Obama’s FY2010 Budget requests no funding for the program,
arguing that this program has not demonstrated effectiveness in improving child and adult
learning outcomes.
Healthy Start
The Healthy Start program provides funding through competitive grants or cooperative
agreements to provide health and related services to high-risk pregnant women, infants, and
mothers in communities with exceptionally high rates of infant mortality. Among other purposes,
the program seeks to reduce racial and ethnic disparities in the proportion of pregnancy-related
maternal deaths, preterm births, and infant mortality. Healthy Start projects also work to ensure
that the basic needs of mothers and infants (including “housing, psychosocial, nutritional and
education support, and job skill building”) are met. The program operates in 40 states (including
the District of Columbia and Puerto Rico) and reaches roughly 100 communities.163
Home visits are frequently a part of services offered under this program. A 2003 survey of
Healthy Start grantees (n=95) found that 99% provided home visits to at least some of their
clients, with most offering home visits to a majority of their pregnant or parenting clients: 76% of
grantees provided home visits to at least three-fourths of their pregnant clients and 64% of
grantees provided home visits to their inter-conceptional clients. A little more than one-third of
the grantees (35%) used a specific schedule to provide these home visits, but most (64%) reported
scheduling visits in accordance with client need. Home visiting services provided to Healthy Start
clients frequently included depression screening and treatment (84%), well baby care (75%), and
smoking cessation and reduction services (73%). The large majority of grantees (87%) also
conducted home visits to assess the home environment for infants and toddlers.164 The program is
authorized under the Public Health Service Act (Section 330H, as amended by P.L. 106-310) and
is administered by the Maternal and Child Health Bureau within the Health Resources and
Services Administration (HRSA) of HHS. For FY2009, it received funding of approximately
$100 million.
Infants and Toddlers Program, Part C, IDEA
The Infants and Toddlers Program (“Part C”) component of the Individuals with Disabilities
Education Act (IDEA) provides grants to states to assist them in implementing statewide systems
of “coordinated, comprehensive, multidisciplinary, interagency programs” that identify children
(ages birth through three) that have or are at risk of physical, mental, or social skills
developmental delays.165 The Part C program may be targeted toward children experiencing a
163 U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), FY2010
Justification of Appropriations Estimates for Congress, pp. 166-171.
164 U.S. Department of Health and Human Services, Health Resources Services Administration (HRSA), Maternal and
Child Health Bureau, A Profile of Healthy Start: Findings from Phase I of the Evaluation, 2006, pp.11-12.
165 The Act (Section 602(3)(B)(i)) leaves the definition of developmental delay to the states, except to enumerate that
delays may occur in one or more areas (physical, cognitive, communication, social/emotional, or adaptive
(continued...)
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developmental delay in one or more physical, mental, or social skill areas; The IDEA requires that
these Part C services be delivered to the “maximum extent possible” in a child’s “natural
environment,” and the very large majority of Part C services are delivered in the home.166 In fact,
one report indicates that more than 80% of Part C Services are delivered in the home.167 However,
specific services are not based on any statutorily developed curriculum. Instead, they are provided
pursuant to an Individual Family Services Plan (IFSP) that must be created to address the
identified developmental delays. The Part C program is administered by the Office of Special
Education within the Department of Education. The program received an annual appropriation of
$436 million in FY2009. (The American Recovery and Reinvestment Act, P.L. 111-5,
appropriated $500,000 in additional funding for this program in FY2009.) 168
Maternal and Child Health Block Grant
The Maternal and Child Health Block grant (Title V of the Social Security Act) is a public health
program that seeks to 1) ensure access to and improve the quality of health care for mothers and
children, especially those with low income or limited availability of care; 2) reduce infant
mortality; 3) provide and ensure access to comprehensive prenatal and postnatal care to women
(especially low-income and at-risk pregnant women); 4) increase the number of children
receiving health assessments and follow-up diagnostic and treatment services; 5) provide and
ensure access to preventive and child care services as well as rehabilitative services for certain
children; 6) implement family-centered, community-based systems of coordinated care for
children with special health care needs; and 7) provide toll-free hotlines and assistance in
applying for services to pregnant women with infants and children who are eligible for Medicaid.
States use Title V block grant funds for a variety of purposes, including direct services; efforts to
build community capacity to deliver “enabling services” (e.g., home visiting, care coordination,
transportation, and nutrition counseling); personal and preventive health services; and
infrastructure-building services. Separately, Title V funds Community Integrated Service Systems
(CISS). These projects use six specified strategies to increase capacity and integration of local
service systems, including through provision of maternal and infant home health visiting, health
education, and related support services for pregnant women and infants up to one year old.169
The Title V program received FY2009 funding of $662 million, of which $554 million was
distributed to all states under the block grant, $10 million was provided for CISS grants and $93
million was devoted to research via the Special Projects of Regional and National Significance
(SPRANS) grants. The Title V block grant is administered by the Maternal and Child Health
Bureau within the Health Resources and Services Administration (HRSA) at HHS.170
(...continued)
development) and to require that appropriate diagnostic assessments are to be used to determine such delays.
166 Ibid, pp. I-41 and I-48.
167 NCCP “Focus on Home Visiting” webinar, 2008.
168 U.S. Department of Education, “Special Education,” in Justifications of Appropriations Estimates to Congress,
FY2010, pp. I-41 and I-48.
169 Ibid. Christie Provost Peters, The Title V Maternal and Child Health Block Grant, National Health Policy Forum,
George Washington University, September 24, 2007.
170 U.S. Department of Health and Human Services, Health Resources and Services Administration, FY2010
Justification of Estimates for Appropriations Committees, May 2009, p. 139-149.
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New Parent Support Program
The military’s New Parent Support Program (NPSP) was developed in recognition of the unique
parenting challenges faced by military families (e.g., frequent deployments, long duty hours,
moves to unfamiliar locations, and separation from extended families and friends). NPSP services
are available to military families who are expecting a child, or who have a child or children up to
three years of age (or five years of age for the Marine Corps). Services offered may vary across
military branches and installations, but all NPSP programs include a home visiting component. In
addition, programs may include supervised playgroups, prenatal and parenting classes, hospital
visits, and referrals to other resources. Home visitors provide parents with guidance on child
growth and development and address topics such as breastfeeding, sleeping, nutrition, and
behavior management. The Department of Defense notes that home visits per family may be
limited unless the family has been identified as being at high risk for child abuse. Every
professional NPSP program staff member is required to be licensed as a Licensed Clinical Social
Worker (LCSW), Marriage and Family Therapist, or Registered Nurse (RN). In addition, all staff
must complete a criminal background check. The NPSP program is a part of the military’s Family
Advocacy Program (FAP). 171
Parent Information Resource Centers
Parent Information and Resource Centers (PIRCs) help implement parental involvement policies,
programs, and activities designed to improve student academic achievement and strengthen
partnerships among parents, teachers, principals, administrators, and other school personnel in
meeting the education needs of children. The Elementary and Secondary Education Act (ESEA)
(Section 5563) requires the recipients of PIRC grants to serve both rural and urban areas; use at
least half their funds to serve areas with high concentrations of low-income children; and use at
least 30% of the funds they receive to establish, expand, or operate Parents as Teachers (PAT)
programs, HIPPY programs, or other early childhood parent education programs. Projects
generally include a focus on serving parents of low-income, minority, and limited English
proficient (LEP) children enrolled in elementary and secondary schools. According to the most
recent data available, nearly 60% of parents served in the 2006-2007 school year were from low-
income families, and nearly 25% had limited English proficiency. PIRC funding is distributed
through competitive grants to nonprofit organizations or a consortium of a nonprofit organization
and a local education agency (LEA). The FY2009 Omnibus (P.L. 110-8) included $39 million for
PIRC grants, of which about 30% (roughly $11.7 million) may go toward PAT, HIPPY, or other
early childhood parent education programs selected by the grantee. PIRC grants are administered
by the Office of Innovation and Improvement (OII) at the Department of Education.
Promoting Safe and Stable Families
The Promoting Safe and Stable Families program (PSSF, Title IV-B, Subpart 2 of the Social
Security Act) primarily authorizes funds to state child welfare agencies for provision of four
categories of services. The statute requires that states spend a “significant” amount of program
171 See an overview of the NPSP on the Department of Defense’s Military Homefront website at
http://www.militaryhomefront.dod.mil/portal/page/mhf/MHF/MHF_HOME_1?section_id=20.40.500.420.0.0.0.0.0.
and military one source website at http://www.militaryonesource.com/MOS/FindInformation/Category/Topic/Issue/
Material.aspx?MaterialID=14058.
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funding on each of the categories: family support, family preservation, time-limited reunification
(for families whose children have been removed to foster care within the past 15 months), and
adoption promotion and support. For FY2009, the PSSF program received funding of $408
million, of which an estimated $64 million, at a minimum, should be made available for family
support services. Home visitation is typically considered a family support service and the
statutory definition of “family support services” for purposes of the PSSF program is
“community-based services to promote the safety and well-being of children and families
designed to increase the strength and stability of families (including adoptive, foster, and
extended families), to increase parents’ confidence and competence in their parenting abilities, to
afford children a safe, stable and supportive family environment, to strengthen parental
relationships and promote healthy marriages and otherwise to enhance child development.” 172
Current data on the number of states using PSSF dollars to support home visitation are not
available. The PSSF program is administered by the Children’s Bureau within the Administration
for Children and Families at HHS.
172 Section 431(2) of the Social Security Act. The PSSF statute also defines “family preservation services” in terms that
could be used to encompass home visitation. However, family support services—like most home visitation programs—
are considered to be primary prevention services, whereas family preservation services are generally secondary
prevention/interventions.
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Appendix B. Federal Initiatives Related to
Coordination of Early Childhood Programs
and Services
Researchers have noted the importance of providing home visitation services in the context of
other community supports intended to support and improve the well-being of young children and
their families.173 In recent years, a number of federal initiatives have been established that seek to
improve coordination among early childhood health, education, and social services programs and
which might be relevant to home visitation programs. Several are discussed below.
State Advisory Councils on Early Childhood Education and Care
The 2007 reauthorization of Head Start (P.L. 110-134) 2007 included a new requirement for
governors to establish State Advisory Councils on Early Childhood Education and Care ( “State
Advisory Councils”) for children from birth to school entry. These councils are intended to
improve coordination across critical early childhood programs within each state and are expected
to have representation from a broad spectrum of stakeholders, ranging from the state child care
and education agencies to agencies responsible for health and mental health care.174 State
Advisory Councils must:
• conduct a statewide needs assessment;
• identify opportunities for collaboration and coordination among entities carrying
out federally funded and state-funded child development, child care, and early
childhood education programs;
• develop recommendations for increasing the participation of children in existing
federal, state, and local early childhood education and child care programs;
• develop recommendations for establishing a unified data collection system for
publicly funded programs offering early childhood education, development, and
services;
• develop recommendations for a statewide professional development and career
plan for early childhood education and care;
173 Heather Weiss, et. al., Changing the Conversation About Home Visiting: Scaling up with Quality, Harvard Family
Research Project, Harvard Graduate School of Education, December 2006. American Academy of Pediatrics, Council
on Child and Adolescent Health, “The Role of Preschool Home-Visiting Programs in Improving Children’s Health and
Developmental Outcomes,” Pediatrics, v. 123 (2009), pp. 598-603. Testimony of Deborah Daro before the Committee
on Ways and Means, Subcommittee on Income Security and Family Support, June 9, 2009.
174 Section 642B(b)(1)(C) of the Head Start Act specifies that State Advisory Councils are expected (to the extent
possible) to include representatives from (1) the state child care agency, (2) the state education agency, (3) local
education agencies, (4) higher education institutions within the state, (5) local providers of early childhood education
and development services, (6) Head Start agencies within the state (including migrant and seasonal Head Start and
Indian Head Start, as appropriate), (7) the state director of Head Start collaboration, (8) the state agency responsible for
programs under section 619 or part C of the Individuals with Disabilities Education Act, (9) the state agency
responsible for health or mental health care, and (10) other representatives deemed relevant by the governor.
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• assess the capacity and effectiveness of two- and four-year public and private
institutions of higher education toward supporting the development of early
childhood educators; and
• make recommendations for improvements in state early learning standards, as
appropriate.
The Head Start Act requires that governors officially “designate” a council to serve as the State
Advisory Council and an individual to coordinate the activities of the council (which might be a
pre-existing advisory council). The Head Start Act allows HHS to award one-time start-up grants
of $500,000 or more to states for the development or enhancement of high-quality systems of
early childhood education and care designed to improve school preparedness. Funding ($100
million) was made available for these grants for the first time in FY2009.175 Grantees are required
to provide a 70% match. All Head Start activities, including State Advisory Councils, are
administered by the Office of Head Start within the Administration for Children and Families at
HHS.
Early Childhood Comprehensive Systems
State Early Childhood Comprehensive Systems (ECCS) are funded via competitive grants to
states, and are to ensure school readiness through creation of a seamless system of early
childhood services for all children. There are five core areas in which these systems, by fostering
integrated efforts across health, human service, and education agencies, are meant to ensure
delivery of services for young children. The five areas are 1) access to health care and medical
homes; 2) assessment of and services to address socio-emotional development and mental health
needs; 3) early care and learning programs; 4) parenting education; and 5) family support
services. The initiative, which is supported with a part of the Title V (of the Social Security Act)
Maternal and Child Health Block Grant funding reserved for Special Projects of Regional or
National Significance (SPRANS), was first funded in FY2003 and received FY2009 funding of
just over $7 million. As of FY2007, nearly all states received these grants and were developing or
implementing these systems. States have tended to focus ECCS activities on state early care and
learning policies and programs, and one analysis concluded that “most states need to give more
importance to strategies that promote health, mental health, and family support.” Home visiting is
one family support strategy that is generally consistent with the overall school readiness aim of
the initiative and which has received specific attention by some ECCS grantees. In its
announcement of FY2009 funding, the Maternal and Child Health Bureau (HRSA, HHS), stated
that this phase of the initiative was expected to support continued implementation of the state
early childhood strategic plans and “the integration of the ECCS program with the Substance
Abuse and Mental Health Services Administration’s Project LAUNCH [described below in this
Appendix], the Administration for Children and Families Home Visiting Program [see “Current
ACF Home Visitation Initiative”], and the State Early Learning Councils mandated by the Head
Start reauthorization legislation [described above in this Appendix].”176
175 For more information about FY2009 funding for State Advisory Councils, visit http://eclkc.ohs.acf.hhs.gov/hslc/
Program%20Design%20and%20Management/sac/ARRA_HS_funds.html.
176 U.S. Department of Health and Human Services, Health Resources and Services Administration, State MCH Early
Childhood Comprehensive System Implementation Grants, HRSA-090176, 2009. U.S. Department of Health and
Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, State Early
Childhood Comprehensive Systems Program, Announcement Type: Competing Continuation, Program Guidance Fiscal
(continued...)
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Project LAUNCH
The Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health) initiative
provides competitive grants for states and tribes to promote the wellness (defined as positive
physical, emotional, social, and behavioral health) of children from birth to age eight.177 Grantees
are charged with supporting evidence-based initiatives to achieve the overall goal of wellness. In
their November 2008 applications, each grantee identified multiple programs to support, and all
but one state (Rhode Island) identified one or more specific home visitation models. These
included Parents as Teachers, Healthy Steps Home Visitation Component, Baby University Nurse
Home Visiting Program, First Born Home Visiting Program, Safe Care, and “Visitation to at-risk
infants and parents by Touchpoints trained visitors.” In addition, grantees identified numerous
additional parent training and family strengthening programs, along with programs focused on
developmental assessments, mental health, and physical health. Among other requirements,
grantees are required to create a State (or Territorial or Tribal) Council on Young Child Wellness
and to include public agencies that administer health, education, and human services for young
children (including child welfare agencies). In addition, grantees are specifically required to link
their efforts to those of any HRSA-funded ECCS grantee in the state as well as any ACF Home
Visitation grantee.178 Initial funding of just under $7.5 million was provided for FY2008 (P.L.
110-161) under authority of Section 520A of the Public Health Service Act; for FY2009 Congress
provided $20 million for the initiative (P.L. 111-8).179 Consequently, the number of grantees is
expected to grow beyond the seven cooperative agreements that were funded in the initial year of
the initiative. The program is administered by the Center for Mental Health Services within the
HHS, Substance Abuse and Mental Health Services Administration (SAMHSA).
Interagency Coordinating Councils
The Individuals with Disabilities Education Act (IDEA)180 requires that each state establish a state
Interagency Coordinating Council, appointed by the governor of the state, for the purpose of
advising and assisting the state’s lead agency in the implementation of the Part C program. States
receiving funds under Part C are expected to establish such a council. The statute gives governors
authority to appoint members to the council and goes on to specify a broad spectrum of early
(...continued)
Year 2009, February 5, 2009. National Center for Children in Poverty, Columbia University Mailman School of Public
Health, State of States’ ECCS Initiatives, Project Thrive, Short Takes No. 5, July 2007 at http://nccp.org/publications/
pub_748.html. NCCP, “About Early Childhood Comprehensive Initiatives,” at http://www.state-eccs.org/
componentareas/index.htm.
177 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Mental Health Services (CMHS), Grant Announcement: Project LAUNCH, April 16, 2008, at
http://www.samhsa.gov/grants/2008/sm_08_011.aspx.
178 National Center for Mental Health Promotion and Youth Violence Prevention, “LAUNCH Links,” vol. 1, Issue 2,
March 2009. “Evidence-based Practices Proposed by Project LAUNCH Grantees,” as of November 2008 at
http://projectlaunch.promoteprevent.org/EBP_Proposed_by_PL_Grantees_Chart_As_of_11_2008.doc.
179 Funding for Project LAUNCH appears to have followed from a Congressional request that the HHS, SAMHSA,
Center for Mental Health Services support a “wellness initiative” to “assist local communities in the coordination and
improvement of the integration of behavioral/mental and physical health services.” See Joint Explanatory Statement
Accompanying Division G of H.R. 2764, P.L. 110-161, p. 1528, and Explanatory Statement for Division F, H.R. 1105,
P.L. 111-8, p. 1411.
180 See section 641 of the IDEA.
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childhood stakeholders that should be included.181 At least 20% of council members must be
parents of children with disabilities, a requirement that emphasizes the role of family involvement
in policy and program development. The IDEA state councils are required to meet on a quarterly
basis and council meetings may be open to the public. State councils are responsible for advising
and assisting the lead state agency in the identification of fiscal and other resources for early
intervention programs. Moreover, the councils may advise and assist the lead agency and the state
educational agency on the provision of appropriate services for children from birth through age
five, including the transition to preschool. The councils may also advise appropriate agencies in
the state with respect to the integration of services for infants and toddlers with disabilities and at-
risk infants and toddlers and their families, regardless of whether at-risk infants and toddlers are
eligible for early intervention services. The councils are also required to prepare an annual report
on the status of the state’s early intervention programs for infants and toddlers with disabilities
and their families.
Author Contact Information
Emilie Stoltzfus
Karen E. Lynch
Specialist in Social Policy
Analyst in Social Policy
estoltzfus@crs.loc.gov, 7-2324
klynch@crs.loc.gov, 7-6899
Acknowledgments
We are grateful to Jennifer Reed, whose work as a visiting research associate at the Congressional Research
Service during the summer of 2007 laid significant groundwork for this report.
181 IDEA statute makes the governor responsible for ensuring that the membership of the council “reasonably
represents” the population of the state. Composition of the council is expected to include parents of infants, toddlers, or
children with disabilities (at least 20%) as well as public or private providers of early intervention services (at least
20%). In addition, the council should include at least one member representing the following agencies and/or
qualifications: (1) the state legislature; (2) each of the state agencies involved in early intervention; (3) the state
educational agency responsible for preschool services for children with disabilities; (4) the state Medicaid agency; (5) a
Head Start agency or program; (6) the state agency responsible for child care; (7) the state agency responsible for state
regulation of health insurance; (8) the Office of Coordinator for Education of Homeless Children and Youths; (9) the
state child welfare agency overseeing foster care; and (10) the state agency responsible for children’s mental health.
The council must also include at least one member who is involved in personnel preparation and may include other
members of the governor’s choosing, including a representative from the Bureau of Indian Affairs, the Indian Health
Service, or the tribal council.
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