Contents

• Introduction
• Current Practices and Initiatives in Home Visiting
• Review of Selected Home Visiting Models
• Target Population
• Age of Child When Service Begins and Ends
• Length of Home Visits
• Staff Qualifications and Training
• Goals
• Implementation of Home Visiting by States
• Current ACF Home Visiting Initiative
• Status of the ACF Home Visiting Initiative
• Existing Federal, State, and Local Funding Streams for Home Visiting
• Federal Funding Sources
• State and Local Funding Sources
• Funding Sources by Home Visiting Model
• Current Investment In and Estimated Costs of Home Visiting
• Research and Evaluation of Existing Home Visiting Programs
• Methods for Evaluating Program Models
• Research Findings by Desired Program Outcomes
• Findings in the Maternal and Child Health Domain
• Findings in the Child Social, Emotional, and Cognitive Development Domain
• Findings in the Family/Parent Functioning Domain
• Recent Administration and Congressional Proposals to Support Home Visiting
• Home Visiting Program Proposed by the Obama Administration
• FY2010 Budget Resolution
• Proposed Grants to States for Home Visitation in Health Care Legislation
• Proposed Nurse Home Visitation Services Under Medicaid
• Hearing on Proposals to Support Early Childhood Home Visitation

Summary

Health care reform legislation passed by the House in November 2009 (H.R. 3962) and in the Senate in December 2009 (H.R. 3590) would authorize and provide funds for grants to states to provide home visiting services, on a voluntary basis, to families with young children. (For a comparison of selected provisions in those proposals, see Table 4). There is no current law program that provides grants to states exclusively for home visiting programs. The Obama Administration requested authorization and funding for such a program as part of its FY2010 budget request. This proposal was not included in the President's FY2011 budget request, although the Administration has indicated its expectation that the pending health care reform legislation will be enacted.

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. This report will be updated as warranted.

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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 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 effort (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, 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 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.

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.)

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 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 Visiting Initiative

As part of its FY2008 Budget Request, 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 competitive grants to encourage and enable states to invest existing funding streams in a range of "administrative mechanisms" that are "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 provided an initial $10 million dollars for this purpose as part of its FY2008 appropriations process (P.L. 110-161) ¹⁵ and 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." ¹⁶

The grants are valued at $500,000 per year and, if appropriations are available, are expected to continue for five years. The successful grantees are implementing (or enhancing) and studying 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.¹⁷

Recipients of the cooperative agreement award spent the majority of the first year under the agreement (i.e., most of FY2009) engaged in collaborative planning efforts. Among other things, the collaborative planning effort was meant to ensure that "all relevant programs and funding streams are identified and included" in the coordination efforts. Ultimately, the plan was 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.¹⁸ 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).¹⁹ (For more 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)²⁰ 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.) ²¹

Status of the ACF Home Visiting Initiative

Funding provided in years two through five of the ACF home visiting initiative are to be used for plan implementation. In P.L. 111-8, Congress directed that $13.5 million be set aside to continue the home visitation initiative for a second year. ²² However, no specific funding for the initiative was included in the FY2010 Consolidated Appropriations Act (P.L. 111-117). The statement of the managers on the FY2010 appropriations bill (H.Rept. 111-366) suggests that the conferees did not necessarily expect the current ACF home visiting initiative to end. Instead, it stated that they "anticipate that mandatory funding will be provided for this activity in fiscal year 2010 as proposed by the Administration." As part of its FY2010 budget request, the Obama Administration sought continued funding for the current ACF home visiting initiative, while it separately requested legislative authority to establish a new state grant program that would support home visits to low-income mothers and pregnant women. For the newly proposed program, the Obama Administration sought mandatory (capped entitlement) funds. ²³ As noted above, both the House-passed (H.R. 3962) and the Senate-passed (H.R. 3590) health care reform bills would establish a state grant program to support evidence-based home visiting programs for low-income families with young children and those expecting children. Nothing in the current health care reform proposals would require states that receive funds under the new grant program to continue support of the ACF home visiting grantees. However, neither bill would necessarily preclude a state from providing that support. In its FY2011 budget justifications for Congress, the Administration notes that a third year of funding was not appropriated for this initiative under the CAPTA discretionary activities account. However, it notes that, as discussed above, the conference report to the FY2010 appropriations act anticipated mandatory funding would be available for this purpose.²⁴

Existing Federal, State, and Local Funding Streams for Home Visiting²⁵

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.²⁶ 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.²⁷

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; 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). ²⁸

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;²⁹ the Corporation for National and Community Service, an independent agency which supports home visiting through AmeriCorps programs;³⁰ and the Department of Defense, which funds home visiting efforts as part of its New Parent Support Program for families with children ages 0-3.³¹

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 Start³²) or an explicitly permitted (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 strategy³³ 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.

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.³⁴ One study published in 2001 found that 44% of the reported home visiting program budget dollars came from state revenues.³⁵ 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.³⁶

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.³⁷

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. ³⁸ 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.³⁹ 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 America⁴⁰ 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.⁴¹ In subsequent years, the Maternal and Child Health Bureau 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.⁴² 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).⁴³ 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).⁴⁴ 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.⁴⁵

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.⁴⁶ 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."⁴⁷ The Even Start (Title I, Part B) statute allows for the provision of funds to "eligible organizations" for program improvement and replication activities.⁴⁸ 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.

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 million⁴⁹ 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."⁵⁰

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).⁵¹ 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 FY2008.⁵² 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.⁵³

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.⁵⁴ 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 $2,914 to $6,463 per family per year.⁵⁵ 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.⁵⁶ 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).⁵⁷

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.⁵⁸ 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.⁵⁹

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 homes⁶⁰ 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. ⁶¹

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.

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.⁶² 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.⁶³ 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."⁶⁴ 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.⁶⁵ 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.⁶⁶

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.

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.⁶⁷

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.⁶⁸ 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.⁶⁹ 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.⁷⁰

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 has been linked to higher rates of behavioral, academic, and health problems among children.⁷¹ 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.⁷² 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.⁷³

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.⁷⁴ The same Hawaii Healthy Start Program study found that home visitation had no statistically significant effect on maternal substance abuse.⁷⁵ 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."⁷⁶ 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.⁷⁷ The nine-year follow-up to the NFP's program in Memphis, TN, found that nurse-visited mothers used fewer substances.⁷⁸ However, this evaluation found no statistically significant effect on maternal depression.

Number and Frequency of Subsequent Pregnancies

Some researchers argue that "rapid successive pregnancies" can negatively affect mothers' educational and workforce achievements.⁷⁹ 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.⁸⁰ 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.⁸¹ 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.⁸² 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).⁸³ 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.⁸⁴

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%). ⁸⁵ By contrast, the randomized trial evaluation of the Hawaii Healthy Start program showed no effects on repeat births.⁸⁶

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.⁸⁷ 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.⁸⁸ 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).⁸⁹

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%).⁹⁰ 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%).⁹¹ 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%).⁹² 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 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.⁹³ However, this same study found no differences in the rates of immunization or well-child visits for participating children compared to control group children.⁹⁴ 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.⁹⁵

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 home⁹⁶ for all children.⁹⁷

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.⁹⁸ 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.⁹⁹

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.¹⁰⁰

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.¹⁰¹ 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,¹⁰² HIPPY,¹⁰³ or the Parent-Child Home Program¹⁰⁴ have demonstrated that home visited children outperform other children in the community through the 4^th, 6^th, or 12^th grades, respectively, in measures such as school grades and achievement test scores on reading and math, suspensions, or high school graduation rates.¹⁰⁵ 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.¹⁰⁶ 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.¹⁰⁷ In contrast, control group children with low-resource mothers had the lowest GPAs in the study.¹⁰⁸ 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.¹⁰⁹) 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.¹¹⁰

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,"¹¹¹ 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"¹¹² 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.¹¹³ 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.

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.¹¹⁴ 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).¹¹⁵ Others have suggested that the center-based preschool education component accounted for 63% of the variance in cognitive outcomes during the preschool years.¹¹⁶ 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.¹¹⁷

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.¹¹⁸ On the other hand, not all home-based Early Head Start programs have demonstrated positive effects on cognitive development.¹¹⁹ 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.¹²⁰ However, recent studies have found that full implementation of HHS performance standards can affect program effectiveness.¹²¹ 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).¹²² Studies have found that some of the largest gains from Early Head Start programs occur in the programs that combine center-based and home-based services, with some effects in the 20-30% range.¹²³ 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.¹²⁴ This held true, even at the three year mark, for participating children and families.¹²⁵

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.¹²⁶

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).¹²⁷ 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.¹²⁸ Other studies have shown no statistically significant results. Implementers of Healthy Families America home visitation programs were encouraged early on 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%).¹²⁹ However, a subsequent randomized control study of the program did not find any significant program effect with regard to rates of child maltreatment. ¹³⁰ 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.¹³¹

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.¹³² 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.¹³³

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 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.¹³⁴ An evaluation of SafeCare implementation found that parents receiving the training were more likely to engage in positive parent behaviors.¹³⁵

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).¹³⁶ 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).¹³⁷ 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.¹³⁸

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.¹³⁹ In the initial 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 15^th 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.¹⁴⁰ 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.¹⁴¹ 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.¹⁴²

Recent Administration and Congressional Proposals to Support Home Visiting

The President's FY2010 budget request included 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 the health care reform proposals passed by the House in November 2009 (H.R. 3962) and Senate in December 2009 (H.R. 3590) would both establish a program of, and provide funding for, grants to states to support the expansion of home visiting to families with young children and those expecting children. The FY2011 budget does not make specific reference to establishing a home visiting program.

Home Visiting Program Proposed by the Obama Administration

As part of its FY2010 budget request the Obama Administration proposed 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 mothers and pregnant women. It expected the program to "create long-term positive impacts for children and their families, as well as generate long-term positive impacts for society as a whole."¹⁴³ Outcomes the Administration cited 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. Further, it noted 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.¹⁴⁴

Mandatory funding for the newly proposed home visitation program was proposed at $124 million in budget authority ($87 million in "outlays"¹⁴⁵) for 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).¹⁴⁶ This funding was expected to allow home visiting services to 50,000 families in the initial year of the program, rising to 450,000 new families by FY2019.¹⁴⁷

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 proposed that no less than 5% of the program's overall funding be reserved for research, evaluation, training, technical assistance, monitoring, and administration.¹⁴⁸

Based on its inclusion in the Administration for Children and Families (ACF) budget justifications, the Obama Administration expected this HHS agency to administer the new home visiting state grant program. At the same time, the FY2010 budget request noted an effort to coordinate planning for the proposal across HHS agencies to ensure the most effective program structure. It also added 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."¹⁴⁹

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 passed, separately, in the House and in the Senate would establish a program of grants to states to support expanded delivery of evidence-based home visitation services to families with young children and those expecting children. The Affordable Health Care for America Act (H.R. 3962), as passed by the House on November 7, 2009, would appropriate $750 million over five years (FY2010-FY2014) for the new grant program it authorizes. On the Senate side, the Patient Protection and Affordable Care Act (H.R. 3590), as passed by the Senate on December 24, 2009, would appropriate $1.5 billion over five years (FY2010-FY2014) for the home visiting grants it authorized. ¹⁵⁰

Table 4 below compares major similarities and differences in these proposals. There is no current law program that provides grants to states exclusively for the purpose of funding home visiting programs. The first column of the table lists general provisions and primarily describes the substantively similar approaches taken. The second and third columns describe aspects of the House and Senate bills, respectively, that are related to that general provision but differ, to some degree, from each other. Differences may be substantive (e.g., different funding levels or different requirements), may be primarily a difference in wording (e.g., one bill more explicit or detailed than the other on purposes of the grant program) or may reflect a different approach to the same issue (e.g., both bills support home visiting provided on voluntary basis only, but one bill requires a state to have a procedures to ensure participation is voluntary and another simply provides that states may not seek federal payment for services not provided on a voluntary basis).

Proposed Nurse Home Visitation Services Under Medicaid

Separately, the proposal passed by the House (H.R. 3962) would amend Medicaid to clearly permit states to claim federal reimbursement for "nurse home visitation services" provided to certain Medicaid eligible individuals. The Senate-passed bill (H.R. 3590) does not include a comparable amendment to Medicaid.¹⁵¹

Section 1713 of the House bill (H.R. 3962), 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%)¹⁵² 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 benefit would be effective for services offered on or after January 1, 2010. H.R. 3962 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.¹⁵³

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.

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.¹⁵⁴ Other factors given as important to program success included solid organizational capacity and linkages to other community resources and supports.¹⁵⁵

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. For FY2010, the CBCAP program received funding of approximately $42 million (P.L. 111-117). 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.¹⁵⁶

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.¹⁵⁷ 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.¹⁵⁸ Children and families enrolled in center-based programs 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).¹⁵⁹

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).¹⁶⁰ 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.¹⁶¹

For FY2010, HHS estimated that Early Head Start programs would receive about $690 million out of the total appropriation provided for Head Start (P.L. 111-117). In addition, Early Head Start programs are expected to receive funds in FY2010 that were appropriated in the previous fiscal year as part of the American Recovery and Reinvestment Act (ARRA), P.L. 111-5. According to HHS, nearly $1.1 billion in Early Head Start funds from ARRA remained unobligated at the end of FY2009.¹⁶² 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.¹⁶³ 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 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 at the level of $66 million for FY2010 (P.L. 111-117).

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.¹⁶⁴

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.¹⁶⁵ 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 FY2010, it received funding of approximately $105 million (P.L. 111-117).

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.¹⁶⁶ The Part C program may be targeted toward children experiencing a 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.¹⁶⁷ In fact, one report indicates that more than 80% of Part C Services are delivered in the home.¹⁶⁸ 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 appropriation of $439 million in FY2010 (P.L. 111-117).

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 FY2010 funding of $662 million (P.L. 111-117), the large majority of which is distributed to all states under the block grant. However, some of these funds are provided for CISS grants and others are 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.

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). ¹⁷⁰

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). For FY2010, PIRC grants were funded at the level of $39 million (P.L. 111-117), 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 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 FY2010, 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." ¹⁷¹ 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.

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.¹⁷² 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.¹⁷³ 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;
• 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. States have until the end of FY2010 to apply for these funds.¹⁷⁴ 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. Nearly all states have now 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 (just over $7 million was made available), 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 Visiting Initiative"], and the State Early Learning Councils mandated by the Head Start reauthorization legislation [described above in this Appendix]."¹⁷⁵

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.¹⁷⁶ Grantees are charged with supporting evidence-based initiatives to achieve the overall goal of wellness. In their applications for funds grantees have sometimes identified one or more specific home visitation models they intend to support. These have 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.¹⁷⁷ 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) and $25 million for FY2010 (P.L. 111-117).¹⁷⁸ The initiative now supports some 25 grantees, many of which are state health departments. 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)¹⁷⁹ 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 childhood stakeholders that should be included.¹⁸⁰ 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.

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.

Footnotes

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).
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.
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.
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."
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 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.
17.	Ibid.
18.	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).
19.	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 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.
20.	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.
21.	The FY2009 funding for Project LAUNCH was $20 million, up from $7.5 million in FY2008. For more information see http://projectlaunch.promoteprevent.org/.
22.	See Congressional Record, February 23, 2009, H.R. 2228. The additional funding will be used to increase support for the original grantees.
23.	U.S. Department of Health and Human Services, Administration for Children and Families, FY2010 Justifications of Estimates for Appropriations Committees, May 2009, p. 122 (hereinafter cited as HHS/ACF, FY2010 Justifications of Estimates).
24.	U.S. Department of Health and Human Services, Administration for Children and Families, FY2011 Justifications of Estimates for Appropriations Committees, February 2010, p. 114.
25.	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.
26.	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.
27.	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
28.	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).
29.	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.
30.	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.
31.	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.
32.	See Title I, Part B, Subpart 3, Section 1235 of the Elementary and Secondary Education Act, which requires that programs "provide and monitor integrated instructional services to participating parents and children through home-based programs."
33.	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.
34.	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).
35.	Johnson, No Place Like Home, 2001.
36.	Galbraith, Proactive Funding, 2007.
37.	Johnson, State-based Home Visiting, 2009.
38.	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.
39.	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.
40.	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.
41.	Andy Goodman, The Story of David Olds and the Nurse Home Visiting Program, Robert Wood Johnson Foundation, July 2006.
42.	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.
43.	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).
44.	See the 2005-2006 HIPPY USA End-of-Year Report online at http://www.hippyusa.org/site/view/136428_HIPPYEndofYearMISReport.pml.
45.	See PAT Fact Sheet at http://www.parentsasteachers.org/atf/cf/%7B00812ECA-A71B-4C2C-8FF3-8F16A5742EEA%7D/PAT%20and%20Title%20I%20ARRA.pdf.
46.	See Title I, Part A, Subpart 1, Section 1118 of the Elementary and Secondary Education Act.
47.	See Title I, Part D, Subpart 16, Section 5563 of the Elementary and Secondary Education Act.
48.	See Title I, Part B, Subpart 3, Section 1232 of the Elementary and Secondary Education Act.
49.	Consistent with Johnson, State-based Home Visiting Programs, 2009, p. 4, and with Clothier and Poppe, Early Care and Education, 2008, Appendix C.
50.	Gomby, Home Visitation, 2005, p. 1.
51.	Johnson, State-based Home Visiting Programs, 2009, p. 4.
52.	Clothier and Poppe, Early Care and Education, 2008, Appendix C.
53.	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.
54.	See HFA website at http://www.healthyfamiliesamerica.org/network_resources/hfa_state_of_state_systems.pdf.
55.	See NFP website at http://www.nursefamilypartnership.org/resources/files/PDF/Fact_Sheets/NFP_Benefits&Cost.pdf.
56.	Galbraith, Proactive Funding, 2007, p. 4.
57.	See FY2008 Head Start Program Fact Sheet online at http://eclkc.ohs.acf.hhs.gov/hslc/About%20Head%20Start/dHeadStartProgr.htm.
58.	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.
59.	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.
60.	As currently used, a "medical home" means provision of primary care in a manner that is "accessible, continuous, 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.
61.	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).
62.	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).
63.	Wasserman, Implementation of Home Visitation, 2006.
64.	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.
65.	Question and Answer Period, NCCP "Focus on Home Visiting," webinar, 2008.
66.	Ibid. Johnson, State-based Home Visiting, 2009.
67.	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.
68.	Sweet and Appelbaum, "A Meta-Analytic Review," 2004.
69.	Gomby, Home Visitation, 2005, pp. 18-19.
70.	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.
71.	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.
72.	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.
73.	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.
74.	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).
75.	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).
76.	Duggan et al., "Impact in reducing parental risk factors," 2004, p. 631.
77.	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.
78.	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.
79.	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.
80.	Research cited in RAND Corp., Promising Practices Network, Programs that Work, Nurse Family Partnership, http://www.promisingpractices.net/program.asp?programid=16#findings.
81.	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.
82.	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.
83.	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.
84.	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.
85.	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.)
86.	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.
87.	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.
88.	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.
89.	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.
90.	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.)
91.	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.
92.	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.
93.	Duggan et al., "Hawaii's Healthy Start Program," 1999, pp. 77, 80.
94.	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.
95.	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.
96.	See footnote 60 for an explanation of the "medical home" concept.
97.	Council on Community Pediatrics, "The Role of Preschool Home Visiting," p. 601. Thompson et al., Home Visiting: A Service Strategy, 2001, p. 27.
98.	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.
99.	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.)
100.	Duggan et al., "Hawaii's Healthy Start Program," 1999, p. 82.
101.	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.
102.	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.)
103.	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.)
104.	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.)
105.	Gomby, Home Visitation, 2005, p. 23.
106.	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.
107.	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.
108.	Ibid.
109.	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.
110.	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.
111.	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.
112.	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.
113.	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.
114.	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.
115.	Layzer, National Evaluation, 2001.
116.	Geoffrey Nelson et al., "A meta-analysis of longitudinal research on preschool prevention programs for children," Prevention & Treatment, vol. 6, no. 1 (December 2003).
117.	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.
118.	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).
119.	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.
120.	Love et al., Making a Difference, 2004, p. 315.
121.	Love et al., Making a Difference, 2004, pp. 303, 317.
122.	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. 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.
124.	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.
125.	Love et al., Making a Difference, 2004, p. 286.
126.	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.
127.	Harriet L. MacMillian et al., "Interventions to Prevent Child Maltreatment and Associated Impairment," The Lancet, vol. 373 (January 17, 2009), pp. 250-266.
128.	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.
129.	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.
130.	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.
131.	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.
132.	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).
133.	RAND Corporation, Promising Practices Network, Programs that Work, "Healthy Families New York," http://www.promisingpractices.net/program.asp?programid=147#findings.
134.	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.
135.	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.
136.	Duggan et al., "Impact in reducing parental risk factors," 2004, pp. 625-645.
137.	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.
138.	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).
139.	RAND Corporation, Promising Practices Network, Programs That Work, "Parents as Teachers," http://www.promisingpractices.net/program.asp?programid=88.
140.	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.
141.	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.
142.	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.
143.	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.
144.	Ibid. U.S. Department of Health and Human Services (HHS), Fiscal Year 2010 Budget in Brief, p. 84.
145.	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.
146.	Office of Management and Budget, Updated Summary Tables, May 2009, p. 24 and communications with ACF.
147.	FY2010 ACF budget justification, p. 268.
148.	Ibid, pp. 267-268.
149.	U.S. Department of Health and Human Services (HHS), Fiscal Year 2010 Budget in Brief, p. 84.
150.	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 visitation provisions included in Section 1904 of H.R. 3962 are most similar to those included in H.R. 2667. In turn, H.R. 2667 and H.R. 3590, as passed by the Senate, 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. 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.
151.	The Healthy Families and Children Act (S. 1052/H.R. 3024 in the 110th Congress) has not been reintroduced in the 111th Congress. However, Section 1713 of the House health care reform proposal (H.R. 3962) draws on a central concept of that bill —defining "medical assistance" under the Medicaid program to include certain nurse home visitation services.
152.	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 [author name scrubbed].
153.	To view hearing testimony, go to http://waysandmeans.house.gov/hearings.asp?formmode=detail&hearing=682.
154.	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).
155.	Written testimony of Deborah Daro, June 9, 2009, p. 5.
156.	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 [author name scrubbed].
157.	See Head Start Program Fact Sheets at http://eclkc.ohs.acf.hhs.gov/hslc/About%20Head%20Start/headstart_factsheet.html.
158.	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.
159.	See relevant regulations at 45 CFR 1306.
160.	Statistics are based on 2007-2008 Program Information Reports (PIR) data. Note that "degree" encompasses associate, baccalaureate, and advanced degrees.
161.	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.
162.	P.L. 111-5 appropriated $1.1 billion specifically for the expansion of Early Head Start. Although HHS issued a funding announcement with the intention of awarding approximately $619 million of these expansion funds in FY2009, the FY2011 Budget in Brief for the U.S. Department of Health and Human Services (available online at http://www.hhs.gov/asrt/ob/docbudget/2011budgetinbrief.pdf) indicates that only $8 million of the Early Head Start ARRA funding was obligated to grantees in that year. This leaves the bulk of funding to be awarded to grantees in FY2010. For more information on Head Start and Early Head Start funding from the ARRA, see CRS Report R40211, Human Services Provisions of the American Recovery and Reinvestment Act, by [author name scrubbed] et al.
163.	For more information, see CRS Report RL30448, Even Start Family Literacy Programs: An Overview, by [author name scrubbed], and CRS Report CRS Report RL33071, Even Start: Funding Controversy, by [author name scrubbed].
164.	U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), FY2010 Justification of Appropriations Estimates for Congress, pp. 166-171.
165.	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.
166.	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 development) and to require that appropriate diagnostic assessments are to be used to determine such delays.
167.	Ibid, pp. I-41 and I-48.
168.	NCCP "Focus on Home Visiting" webinar, 2008.
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.	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.
171.	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.
172.	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.
173.	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.
174.	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.
175.	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 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.
176.	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.
177.	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.
178.	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.
179.	See section 641 of the IDEA.
180.	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.