Valarie Redmond’s experience bringing her first child home may sound familiar to other parents.
“I was just so nervous,” Redmond said. “I had this little baby that I was responsible for. And though I had experience with other people’s children, this was my baby and I wanted to give her the best.”
Unlike many first-time parents, Redmond had support. During her pregnancy, she had learned about a service called home visiting. After delivering her daughter, Alexandria, Redmond went to a local office of the state health department, eager to learn more. Soon, Redmond had a trained home visitor who met with her every week to help her grow into the parent she wanted to be.
“It was school for parenting,” she said.
Redmond liked this one-on-one, home-based “school” experience so much that she later decided to become a home visitor for the same agency, Children’s Home + Aid in Illinois.
“I had been working with youth in higher education,” Redmond said. “And I thought, if they had had a home visitor when they were a child, how much different would their life be? How much more effective could I be if I were on the home front being proactive instead of reactive?”
Early childhood home visiting is a specific service-delivery strategy that brings a trained professional into a new family’s home to help parents meet goals for themselves and their children. Home visiting is predicated on the idea that working with children when they’re young will yield dividends later in life. More than a quarter of a million families nationwide received home visiting services through an evidence-based model in 2015, according to the National Home Visiting Resource Center.
Home visiting takes different forms, and the US Department of Health and Human Services has certified 20 models as evidence based given their demonstrated positive effects on child and family health and development. Each model has a slightly different objective, target population, and approach, but all aim to improve outcomes in the early childhood years and ultimately throughout the child’s life.
“The prenatal and early childhood years are such a critical time in development,” said Allison Meisch, deputy project director for the National Home Visiting Resource Center. “We know that having prenatal care leads to better outcomes—and not just better birth outcomes, but things that go beyond that into the lifespan. These early years are critical and really do set up the trajectory for the child for the rest of their life.”
Stronger families, stronger communities
The need for home visiting is clear. In 2014, 6 percent of expectant mothers had delayed or no prenatal care and 8 percent used tobacco. Nine in every 1,000 children suffered child abuse. Additionally, 1 in 10 mothers suffer from postpartum depression, which can affect not only the mother but her family and children as well.
Home visiting, the evidence shows, can help address these problems and provide a net benefit to the child and the community.
“Your schools are going to be better. Parents are not going to be missing out on work because kids are getting suspended. It allows the community to work,” said Mendy Smith, program director of Family Support Services for Children’s Home + Aid. “And it saves money in the long run. It saves money in special education, the judicial system, ER visits—all of that costs money.”
But millions of families in the United States with children under 6 aren’t receiving home visiting services. According to research by the National Home Visiting Resource Center, 18.3 million families nationwide have a child under 6 or a child on the way, but evidence-based models only reach about 3 percent of these families. Of those 18.3 million families, 52 percent are considered high priority, meaning there is either an infant in the family, the family’s income is below the federal poverty level, the family is headed by a teen mother or single mother, or the parents in the family never completed high school.
“There really is this need out there to help these families during the early childhood phase and during the transition to parenting,” said Jill Filene, project director of the National Home Visiting Resource Center.
What stops states and programs from meeting this need? Sometimes, it’s funding. Other times, states have trouble identifying the families who could benefit from home visiting. And sometimes, programs simply struggle to find qualified, passionate home visitors.
Finding funds to find more families
In Tennessee, the challenge is funding. A recent analysis by the state’s Department of Health found that only 1.9 percent of the 30 percent of children under 5 living in poverty are served by home visiting.
“I know that all mamas and all babies could benefit from home visiting,” said Angie Jones, section chief for early childhood initiatives with the Division of Family Health and Wellness. “But at the end of the day, it’s funding. We get federal funding. We get a little bit of state funding for evidence-based home visiting. But it’s not enough to meet the need.”
Tennessee has taken steps to serve more families with the introduction of the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) in 2010. MIECHV funds the implementation and evaluation of evidence-based home visiting programs. Since 2010, the federal government has invested $1.85 billion in MIECHV, tripling the number of families with access to evidence-based home visiting.
MIECHV funding allowed the Healthy Families East Tennessee program at the Helen Ross McNabb Center to expand into rural counties. Though the program had garnered a positive reputation in Knox County, the move outside the county and into new territory posed a challenge.
“Rural areas, especially ones that we haven’t been present in for a long time, are more resistant to services,” said Stephanie Rollins, program coordinator. “In rural areas, this kind of support is not as common. They depend more on extended family, neighbors, and friends. We may lose touch with a family in a rural area because they’re in a crisis and they back off from us, whereas in the urban areas, a crisis is when the family wants us most.”
To gain a foothold in rural areas, Healthy Families East Tennessee hosted community baby showers. Women came to socialize and play games, but they also learned about the program and got to know the staff. Now, Rollins said, most of the program’s participants come from referrals.
Reaching isolated families
But serving rural populations can pose other challenges. Families in rural communities often feel more isolated, and it can be harder for them to access services or transportation. In east Tennessee, home visitors sometimes deliver child development lessons parents would otherwise miss out on or drive them to services they otherwise couldn’t access.
In Washington State, several rural counties and one Native American tribe have banded together to solve some of the problems inherent to delivering home visiting.
Nurse-Family Partnership, an evidence-based home visiting model, first gained a foothold in Jefferson County and initially had just two part-time nurses. But in 2012, Jefferson County partnered with Kitsap County and the Port Gamble S’Klallam tribe to develop a regional team, and Nurse-Family Partnership now employs six nurses in the region.
The regional partnership helped Kitsap County and the Port Gamble S’Klallam overcome start-up barriers. Nurses now meet in a larger team setting to discuss and address the needs of families in the region. The collaborative approach also helps home visitors better connect families with services in other counties.
For the Port Gamble S’Klallam, home visiting practices worked differently at first but had a similar goal. Initially, the nurse was accompanied by a tribal member who helped put other tribal members at ease. The tribe has since fully accepted the program and is now 1 of 25 tribal communities that have received MIECHV funding.
“Families are really an important part of their community, so to be able to have healthy children, healthy moms, healthy families is really important,” said Yuko Umeda, the Nurse-Family Partnership supervisor for Jefferson County Public Health.
Balancing the work
Washington State has a distinct home visiting funding mechanism. As part of a public-private partnership, the state administers a home visiting account that allows private organizations to invest in home visiting. This allows the state to serve an estimated 8,200 families per year, according to Laura Alfani, home visiting project manager for the Washington State Department of Early Learning. But this system has its drawbacks.
“Everyone wants to go out into the community, which is where they should be,” she said. “But because of the nature of our funding, it has a lot of strings.”
Home visiting has received a lot of political buy-in in Washington State, but that buy-in means that programs sometimes face different reporting requirements even within the same model. The burden of collecting different data for different funders can weigh on home visitors trying to focus on families.
“For those programs that had already been delivering services, MIECHV pushed them to a new level of data benchmarks and data collection,” Alfani said. “It has been an amazing asset for us; it has really allowed us to ramp up our services. But it has also been more administratively challenging than programs have experienced in the past.”
A changing landscape
Though the intense data collection required by MIECHV can be a challenge to implement, it comes with a definite upside.
“We have a lot of data, and we’re now at a really important stage of using it for quality assurance and quality improvement and evaluating our impact on our communities in greater depth,” Alfani said.
The focus on continuous quality improvement, an important component of MIECHV, ensures that programs regularly examine and improve their practices so families are offered the services that best fit their situation and changing needs.
Joan Yengo, chief program officer for Mary’s Center, which oversees most home visiting in Washington, DC, has worked in DC-area home visiting since 1996 and seen firsthand how needs—and services—have changed.
“The families that we’re working with have a lot of trauma,” she said. “There are a lot of parents that, as adults, have undiagnosed developmental challenges, poor literacy, undiagnosed behavioral health concerns, housing challenges. As home visitors, when you’re going into these homes you’re going into homes with families that may have had histories of trauma, depression, discrimination.”
That has been the experience for Redmond, the home visiting participant turned home visitor in Illinois.
Now a program supervisor at Children’s Home + Aid, she recounted one visit with a 19-year-old mom and her 2-year-old son. The son didn’t speak much, but Redmond observed that the mom didn’t speak much to him either. Through worksheets and activities, she learned that the mom had been bullied as a child, which had made her shy and introverted. By diagnosing and addressing the root of the problem, Redmond helped the mom become more assertive, which helped her son respond to verbal cues.
“I had to go back to come forward,” Redmond said.
Looking forward, Redmond and others hope to see home visiting grow—and the states have big plans. Illinois is looking to build on its coordinated intake program, which allows families to be screened once and directed to the right programs, and increase the involvement of fathers. Washington, DC, wants to build a sustainable continuum of care. Tennessee is focused on retaining qualified, high-performing staff. And Washington State is expanding its data capacity to better assure the quality of its services. All four hope to use data to better tell the story of the service they believe in.
After all, as Redmond said, “Parenting doesn’t come with a handbook, but I think home visiting is the closest thing to it.”
RESEARCH Heather Sandstrom, Julia Isaacs, and Charmaine Runes
RESEARCH PARTNERS Jill Filene and Allison Meisch, James Bell Associates
VIDEO Lydia Thompson
EDITING Daniel Matos
This feature story was developed for the National Home Visiting Resource Center and is also available on its website.
The NHVRC is led by James Bell Associates in partnership with the Urban Institute. Support is provided by the Heising-Simons Foundation and the Robert Wood Johnson Foundation.