 
 
 
                                     United States General Accounting Office
          ___________________________________________________________________
          GAO                         Report to the Chairman, Subcommittee
                                      on Labor, Health and Human Services,
                                      Education and Related Agencies,
                                      Committee on Appropriations
                                      U.S. Senate
 
 
          ___________________________________________________________________
          July 1990                   HOME VISITING
 
                                      A Promising Early Intervention
                                      Strategy for At-Risk Families
 
 
 
 
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                 B-238394
 
                 July 11, 1990
 
 
                 The Honorable Tom Harkin
                 Chairman, Subcommittee on Labor, Health and Human
                 Services, Education, and Related Agencies
                 Committee on Appropriations
                 United States Senate
 
                 Dear Mr. Chairman:
 
                 This report, prepared at the Subcommittee's request, reviews
                 home visiting as an early intervention strategy to provide
                 health, social, educational, or other services to improve
                 maternal and child health and well-being.
 
                 The report describes (1) the nature and scope of existing
                 home-visiting programs in the United States and Europe, (2)
                 the effectiveness of home visiting, (3) strategies critical to
                 the design of programs that use home visiting, and (4) federal
                 options in using home visiting.
 
                 This report contains a matter for consideration by the
                 Congress and recommendations to the Secretaries of Health and
                 Human Services and Education.
 
                 As agreed with your office, unless you publicly announce its
                 contents earlier, we plan no further distribution of this
                 report until 30 days from the date of this letter.  At that
                 time, we will send copies to the Secretaries of Health and
                 Human Services and Education and to interested parties and
                 make copies available to others upon request.
 
                 This report was prepared under the direction of Linda G.
                 Morra, Director, Intergovernmental and Management Issues, who
                 may be reached on 275-1655 if you or your staff have any
                 questions.  Other major contributors to this report are listed
                 in appendix V.
 
                 Sincerely yours,
 
 
 
 
                 Charles A. Bowsher
                 Comptroller General
                 of the United States
 
                                          1
 
 
 
 
                                  EXECUTIVE SUMMARY
                                  -----------------
          PURPOSE
          -------
          Families that are poor, uneducated, or headed by teenage parents
          often face barriers to getting the health care or social support
          services they need.  Many experts believe that an effective way
          to reduce barriers is to deliver such services directly in the
          home.  This is known as home visiting.  They also believe that
          using home visiting to deliver or improve access to early
          intervention services--prenatal counseling, parenting
          instruction for young mothers, and preschool education--can
          address problems before they become irreversible or extremely
          costly.
 
          Is home visiting an effective service delivery strategy?  What
          are the characteristics of programs that use home visiting?  Are
          there opportunities to expand the use of home visiting?  The
          Senate Appropriations Subcommittee on Labor, Health and Human
          Services, Education, and Related Agencies asked GAO to answer
          these questions.
 
          BACKGROUND
          ----------
          Home visitors have worked with families in the United States and
          Europe for more than 100 years.  In-home services began when
          public health officials recognized that proper prenatal and
          infant care could reduce infant deaths.  Home visitors provide a
          variety of services--prenatal visits, health education, parenting
          education, home-based preschool, and referrals to other agencies
          and services.
 
          While home visiting can also be used to deliver services to the
          chronically ill and the elderly, this report focuses on
          delivering early intervention services to at-risk families with
          young children.  For this study, GAO reviewed the home-visiting
          literature; interviewed international, federal, state, and local
          program officials and other experts in medical, social, and
          educational service delivery; and reviewed eight programs in the
          United States, Great Britain, and Denmark that used home
          visiting.
 
          RESULTS IN BRIEF
          ----------------
          Home visiting is a promising strategy for delivering or improving
          access to early intervention services that can help at-risk
          families become healthier and more self-sufficient.  Evaluations
          have demonstrated that such services are particularly useful when
          families  both face barriers to needed services and are at risk
          of such poor outcomes as low birthweight, child abuse and
          neglect, school failure, and welfare dependency.  While few cost
          studies of home visiting have been done, they have shown that
 
                                          2

 
 
 
          delivering preventive services through home visiting can reduce
          later serious and costly problems.  But the cost-effectiveness of
          home visiting, compared to other strategies to provide early
          intervention services, has not been well researched.
 
          Not all programs that use home visiting have met their
          objectives.  Success depends on a program's design and operation.
          Well-designed programs share several critical components that
          enhance their chances of success.  Home visiting does not stand
          alone; much of its success stems from connecting clients to a
          wider array of community services.
 
          The federal government's home-visiting activities can be better
          coordinated and focused.  The Departments of Health and Human
          Services (HHS) and Education provide funding for various home-
          visiting services and initiatives.  But the knowledge gained
          through these efforts is not always shared across agencies and
          with state and local programs.  The federal government is
          uniquely situated to strengthen program design and operation for
          home visiting by communicating the wealth of practical knowledge
          developed at the federal, state, and local levels.
 
          GAO'S ANALYSIS
          --------------
          Home Visiting Can Be an Effective Service Delivery Strategy
          -----------------------------------------------------------
          Evaluations of early intervention programs using home visiting
          demonstrate that these programs can improve both the short- and
          long-term health and well-being of families and children.
          Compared to families who were not given these services, home-
          visited clients had fewer low birthweight babies and reported
          cases of child abuse and neglect, higher rates of child
          immunizations, and more age-appropriate child development.
          Evaluations of home visiting that examined costs have
          demonstrated its potential to reduce the need for more costly
          services, such as neonatal intensive care.  However, few
          experimental research initiatives have compared the cost-
          effectiveness of home visiting to that of other early
          intervention strategies.
 
          Successful programs usually combined home visiting with center-
          based and other community services adapted to the needs of their
          target group.  Longitudinal studies showed that visited families
          showed lasting positive effects, including less welfare
          dependency.
 
          Characteristics That Strengthen Program Design and Implementation
          -----------------------------------------------------------------
          Although many early intervention programs using home visiting
          have succeeded, others have failed to meet their stated
          objectives.  Evaluators have attributed such failures to
          fundamental problems with program design and operation.  GAO
 
                                          3
 
 
 
 
          identified critical design components for developing and
          managing programs using home visiting that include (1)
          developing clear objectives and focusing and managing the
          program in accordance with these objectives; (2) planning service
          delivery carefully, matching the home visitor's skills and
          abilities to the services provided; (3) working through an
          agency with a capacity to deliver or arrange for a wide range of
          services; and (4) developing strategies for secure funding over
          time.
 
          Federal Commitment Can Be Better Coordinated and Focused
          --------------------------------------------------------
          HHS and Education support home visiting through both one-time
          demonstration projects and ongoing funding sources, such as
          Medicaid (a federal-state medical assistance program for needy
          people).  But federal managers were not always aware of results
          in other agencies, materials developed through federally funded
          efforts, or state and local home-visiting efforts.
 
          The Federal Interagency Coordinating Council is a multiagency
          body that attempts to mobilize and focus federal efforts on
          behalf of handicapped children or those at risk of certain
          handicapping conditions.  The Council is one federal mechanism
          that can be used to better disseminate information on successful
          home-visiting efforts and encourage collaboration on joint agency
          projects.
 
          Federal demonstration projects could be better focused to improve
          program design and fill information voids.  Federal managers
          should emphasize evaluating potential cost savings associated
          with programs using home visiting and developing strategies to
          *better integrate home visiting into community services,
          especially beyond federal demonstration periods.
 
          The Congress' recent interest in home visiting has focused on
          maternal and child health initiatives, including newly
          authorizing home-visiting demonstration projects through the
          Maternal and Child Health block grant.  The Congress considered
          (but did not pass) legislation to amend the Medicaid statute to
          explicitly cover physician-prescribed home-visiting services for
          pregnant women and infants up to age 1.  The Congressional Budget
          Office estimated that the additional federal fiscal year 1990-94
          Medicaid costs for this initiative would range from $95 million,
          if home visiting were made an optional Medicaid service, to $625
          million, if mandatory.
 
          MATTER FOR CONGRESSIONAL CONSIDERATION
          --------------------------------------
          In view of the demonstrated benefits and cost savings associated
          with home visiting as a strategy for providing early intervention
          services to improve maternal and child health, the Congress
          should consider amending title XIX of the Social Security Act to
 
                                          4
 
 
 
 
          explicitly establish as an optional Medicaid service, where
          prescribed by a physician or other Medicaid-qualified provider,
          (1) prenatal and postnatal home-visiting services for high-risk
          women and (2) home-visiting services for high-risk infants at
          least up to age 1.
 
          RECOMMENDATIONS
          ---------------
          GAO recommends that the Secretaries of HHS and Education require
          federally supported programs that use home visiting to
          incorporate certain critical program design components for
          developing and managing home-visiting services.  The Secretary of
          HHS should specifically incorporate these components into the
          Maternal and Child Health block grant home-visiting demonstration
          projects.
 
          GAO further recommends that the Secretaries
 
          -- make existing materials on home visiting more widely available
             through established mechanisms, such as agency clearinghouses,
 
          -- provide technical or other assistance to more systematically
             evaluate the costs, benefits, and potential cost savings
             associated with home-visiting services, and
 
          -- charge the Federal Interagency Coordinating Council with the
             federal leadership role in coordinating and assisting home-
             visiting initiatives.
 
          AGENCY COMMENTS
          ---------------
          HHS and the Department of Education generally concurred with
          GAO's conclusions and recommendations.  Both agreed with the need
          for more research and evaluation of the costs and benefits of
          home visiting.  Without such data, they expressed reluctance to
          give priority to home visiting over other early intervention
          service delivery strategies.  Education supported the Council as
          a focal point for federal home-visiting activities, although HHS
          believed it to be beyond the scope of the Council's mission.  In
          regard to establishing home visiting as an optional Medicaid
          service, HHS stated that states essentially have the option now
          to cover home visiting under a variety of Medicaid categories of
          service.  GAO believes, however, that amending the Medicaid
          statute to explicitly cover home visiting as an optional service
          would send a clear message to states about the efficacy of home
          visiting, especially for high-risk pregnant women and infants.
 
 
 
 
 
 
 
                                          5
 
 
 
 
                                      CONTENTS
                                      --------
                                                                       Page
                                                                       ----
          LETTER                                                          1
 
          EXECUTIVE SUMMARY                                               2
 
          CHAPTER 1      INTRODUCTION                                    10
 
                         What Is Home Visiting?                          10
 
                         Some Families Face Service Barriers             11
 
                         Home Visiting as an Early Intervention          13
                         Strategy
 
                         Objectives, Scope, and Methodology              15
 
          CHAPTER 2      HOME VISITING IS AN ESTABLISHED SERVICE         17
                         DELIVERY STRATEGY WITH MULTIPLE OBJECTIVES
 
                         Home Visiting Widespread in Europe              17
 
                         U.S. Home Visiting Targeted to Low-Income       19
                         and Special Needs Families
 
                         Funding for U.S. Home Visiting From             21
                         Multiple Agencies
 
                         New Impetus for Home Visiting From Recent       24
                         Legislation
 
          CHAPTER 3      HOME-VISITING EVALUATIONS DEMONSTRATE           30
                         BENEFITS, BUT SOME QUESTIONS REMAIN
 
                         Program Evaluations Show Benefits               30
                         of Home Visiting
 
                         Research Shows Home Visiting Compared to        37
                         Other Strategies Promising, but
                         More Study Is Needed
 
                         Limited Research Shows Home Visiting            38
                         Can Produce Cost Savings
 
          CHAPTER 4      POOR PROGRAM DESIGN CAN LIMIT                   42
                         BENEFITS OF HOME VISITING
 
                         Poor Program Outcomes Linked to                 42
                         Design Weaknesses
 
 
                                          6
 
 
 
 
                         Critical Components for Program                 46
                         Design
 
          CHAPTER 5      A FRAMEWORK FOR DESIGNING PROGRAMS              47
                         THAT USE HOME VISITING
 
                         Clear Objectives as a Cornerstone               49
 
                         Structured Program Delivered by Skilled         52
                         Home Visitors
 
                         Strong Community Ties in a Supportive           55
                         Agency
 
                         Ongoing Funding for Program Permanency          58
 
          CHAPTER 6      CONCLUSIONS, RECOMMENDATIONS, AND AGENCY        62
                         COMMENTS
 
                         Conclusions                                     62
 
                         Matter for Congressional Consideration          66
 
                         Recommendations                                 66
 
                         Agency Comments                                 67
 
          APPENDIXES
 
          APPENDIX I:    Description of the Eight Home-Visiting          70
                         Programs GAO Visited
 
          APPENDIX II:   What Happens on a Home Visit?                  102
 
          APPENDIX III:  Comments from the Department of Education      106
                         (Could not be reproduced for electronic
                         viewing)
 
          APPENDIX IV:   Comments From the Department of Health and     107
                         Human Services (Could not be reproduced for
                         electronic viewing)
 
          APPENDIX V:    Major Contributors to this Report              108
 
          TABLES
 
          TABLE 1.1:     Early Intervention Saves Money                  14
 
          TABLE 2.1:     Home Visiting in Nine Western                   18
                         European Countries
 
 
 
                                          7
 
 
 
          TABLE 2.2:     Federal Programs Used to Fund Home              22
                         Visitor Projects
 
          TABLE 2.3:     Signatories to the FICC Memorandum of           26
                         Understanding
 
          TABLE 5.1:     Characteristics of United States and            48
                         European Programs GAO Visited
 
          TABLE I.1      Program Profile:  Center for Development,       71
                           Education, and Nutrition (CEDEN)
 
          TABLE I.2      Program Profile:  Resource Mothers for          75
                           Pregnant Teens
 
          TABLE I.3      Program Profile:  Roseland/Altgeld Adolescent   79
                           Parent Project (RAPP)
 
          TABLE I.4      Program Profile:  Southern Seven Health         83
                           Department Program (Parents Too Soon and the
                           Ounce of Prevention Components)
 
          TABLE I.5      Program Profile:  Maternal and Child Health     87
                           Advocate Program
 
          TABLE I.6      Program Profile:  Changing the Configuration    90
                           of Early Prenatal Care (EPIC)
 
          TABLE I.7      Program Profile:  Great Britain's Health        94
                           Visitor Program
 
          TABLE I.8      Program Profile:  Denmark's Infant Health       98
                           Visitor Program
 
 
          FIGURES    (Could not be reproduced for electronic viewing.)
 
          FIGURE 1.1     Examples of Programs Using Home Visiting        11
                           to Serve At-Risk Families
 
          FIGURE 3.1:    Students Receiving Preschool and Home Visiting  34
                         Services Were More Successful in Later Years
 
          FIGURE 3.2:    Type and Amount of Services Affect Later        36
                         Reading Ability
 
          FIGURE 5.1     Framework for Designing Home Visitor            49
                           Services
 
 
 
 
 
                                          8
 
 
 
 
          ABBREVIATIONS
          -------------
          AFDC           Aid to Families With Dependent Children
          CEDEN          Center for Development, Education and Nutrition
          EPIC           Changing the Configuration of Early Prenatal Care
          FICC           Federal Interagency Coordinating Council
          GAO            General Accounting Office
          HHS            Department of Health and Human Services
          MCH            Maternal and Child Health
          PTS            Parents Too Soon
          RAPP           Roseland/Altgeld Adolescent Parents Program
          SPRANS         Special Projects of Regional and National
                         Significance
          VISTA          Volunteers in Service to America
          VNA            Visiting Nurses Association, Incorporated
          WIC            Special Supplemental Food Program for Women,
                         Infants, and Children
 
 
                                          9
 
 
 
 
                                      CHAPTER 1
                                      ---------
                                    INTRODUCTION
                                    ------------
          For more than a century in both the United States and Europe,
          home visitors have provided individuals and families with
          preventive and supportive health and social services directly in
          their homes. While not a new concept, home visiting is an
          evolving service delivery strategy that numerous agencies in the
          United States are embracing with renewed enthusiasm, for both
          humanitarian and economic reasons.  Experts believe that
          intervening early in the lives of certain families at risk of
          such negative outcomes as low birthweight, child abuse, and
          educational failure offers them promise of a better future
          through improved health and education.  They also believe that
          home visiting can break down barriers that prevent families from
          accessing the care they need and that preventive services can be
          less costly in the long run than providing more expensive crisis,
          curative, and remedial services.
 
          But what can home visiting do for those families facing many
          interconnected health, social, and educational risks?  Is it an
          effective strategy for delivering services?  What can we learn
          from the experience of Europe, where home visiting is a universal
          service?  The Senate Appropriations Subcommittee on Labor, Health
          and Human Services, Education, and Related Agencies, in its
          search for innovative strategies to reduce threats to the health
          and well-being of disadvantaged families, asked us to answer
          these questions.
 
          WHAT IS HOME VISITING?
          ----------------------
          Home visiting is a strategy that delivers health, social support,
          or educational services directly to individuals in their homes.
          Programs use home visitors of various disciplines and skills to
          accomplish various goals and provide various services. For
          example, home visiting has been used to deliver nutritional
          support to the elderly, medical care to the chronically ill, and
          social support to at-risk families.  This report focuses on the
          home-based services, such as coaching, counseling, teaching, and
          referrals to other service providers for additional services,
          that are offered as a part of early intervention services for at-
          risk families with young children.  Programs designed for such
          purposes can vary in their goals and services, as shown in figure
          1.1.
 
 
 
 
 
 
 
 
                                         10
 
 
 
 
          Figure 1.1:  Examples of Programs Using Home Visiting To Serve
          At-Risk Families
 
               Goals:         Improved parenting skills
                              Enhanced child development
                              Improved birth outcomes
 
               Services:      Information delivery
                              Referrals to other service providers
                              Emotional support
                              Health care
 
               Providers:     Nurses
                              Paraprofessionals
                              Teachers
                              Social workers
 
          Home visiting occurs as a delivery strategy in three basic forms.
          The first is universal, in which all members of a broad
          population receive services.  Great Britain uses public health
          nurses to provide preventive health information and examinations
          directly in the home to all families with newborns, regardless of
          family income status or need.  The other two strategies target
          services to certain families.  One offers a limited number of
          home visits to assess the environment and family situation, to
          provide some basic information, to reinforce positive behaviors,
          or to refer the family to other services as needed.  The other
          targets some families for more intensive services, providing more
          frequent home visits over 1 or more years.  Home visits may be
          part of other program services, which can include center-based
          parenting classes and job training classes, and developmental day
          care or preschool for children.
 
          SOME FAMILIES FACE SERVICE BARRIERS
          -----------------------------------
          At-risk families, especially those who are poor, uneducated, or
          headed by teenage parents, often face barriers to getting the
          health, education, and social services they need.  The barriers
          can be financial, structural, or personal.  Some experts believe
          that home visiting can reduce barriers by providing needed
          services to these families.
 
          Lack of health insurance, the chief financial barrier, prevents
          many at-risk individuals from receiving adequate health care.  An
          estimated 26 percent of the women of reproductive age--14.6
          million--have no health insurance to cover maternity care, and
          two-thirds of these--9.5 million--have no health insurance at
          all.  We reported in 1987#1 that Medicaid#2 recipients and
 
 
         1Prenatal Care: Medicaid Recipients and Uninsured Women Obtain
          Insufficient Care (GAO/HRD-87-137, Sept. 30, 1987).
 
                                         11
 
 
 
 
          uninsured women received later and less sufficient prenatal care
          than privately insured women from the same communities.  Women
          with no insurance must depend on free or reduced-cost care from a
          diminishing number of willing private physicians or from health
          department clinics and other settings usually financed by public
          funds.
 
          Limited community resources, such as numbers of hospitals,
          community health clinics, social service agencies, and individual
          providers able or willing to serve the at-risk population, create
          structural barriers to care.  The Institute of Medicine has
          reported that the capacity of clinic systems used by the at-risk
          prenatal population is so limited that critically important care
          is not always available.#3  Affordable, quality child care for
          disadvantaged families is not keeping pace with the growing
          numbers of single-parent households.  The child welfare system is
          hard-pressed to process the large number of children who now need
          protection.
 
          Inadequate funding for social and medical support programs
          presents an additional structural barrier to the disadvantaged.
          Only half of all poor children are covered by Medicaid.  Fewer
          than half of the 7.5 million individuals eligible for the Special
          Supplemental Food Program for Women, Infants, and Children (WIC)
          receive the program's nutritional support.  Head Start reaches
          only 20 percent of the more than 2.5 million eligible low-income
          children.
 
          The structure of conventional care providers may be insufficient
          to meet the more complex and interrelated needs of the at-risk
          family.  Experts believe that at-risk families need an array of
          services or, at minimum, close coordination among complementary
          service providers.  A pregnant teen, for example, may need, in
          addition to regularly scheduled medical visits, an array of more
          comprehensive services, including counseling and basic parenting
          instruction.  Generally, a mix of related services in one
          location or near one another, or adequate linkages among these
          services, does not exist for at-risk families.
 
          Personal beliefs, knowledge, and attitudes can present additional
          barriers to getting care.  Some researchers have found that some
          low-income families do not understand or value the need for
          preventive services.  They may distrust health care providers or
 
 
         2Medicaid is a federally aided, state-administered medical
          assistance program for needy people, authorized under title XIX
          of the Social Security Act.
 
         3Institute of Medicine, Prenatal Care: Reaching Mothers,
          Reaching Infants, ed. by Sarah S. Brown (Washington, D.C.:
          National Academy Press, 1988), pp. 63-69.
 
                                         12
 
 
 
 
          social workers.  These personal barriers are particularly evident
          in families experiencing social or cultural isolation resulting
          from recent immigration, a lack of friends and relatives that can
          provide emotional support, or substance abuse.
 
          Experts view home visiting as one way to bridge some of these
          gaps.  Providing services to families directly in the home allows
          programs to reach out directly to families who may be facing
          these barriers.  The Office of Technology Assessment, the
          National Academy of Sciences' Institute of Medicine, the National
          Commission to Prevent Infant Mortality, and various private
          organizations and foundations (such as the Pew Charitable Trusts)
          suggest that home visiting allows programs to
 
          -- reach parents who lack self-confidence and trust in formal
             service providers,
 
          -- obtain a more accurate and direct assessment of the home
             environment,
 
          -- link parents with other health and human services, and
 
          -- present a model for good parenting.
 
          Home visitors can support families during major life changes,
          such as the birth of a baby.  Such personalized support may be
          particularly useful for disadvantaged families and families
          headed by teens who suffer from isolation and a lack of an intact
          social support system.
 
          HOME VISITING AS AN EARLY INTERVENTION STRATEGY
          -----------------------------------------------
          Home visiting is often used as one means to provide early
          intervention services.  Early intervention seeks to improve
          families' lives and prevent problems before they become
          irreversible or extremely costly.  For example,
 
          -- prenatal care seeks to promote the health and well-being of
             the expectant mother and developing fetus, thereby reducing
             poor birth outcomes, such as low birthweight;
 
          -- parenting skills instruction for adolescent mothers with
             infant children seeks to promote nurturing skills, thereby
             reducing abusive and neglectful behavior; and
 
          -- preschool education seeks to prepare children for learning,
             thereby reducing later school failure.
 
          The costs associated with low birthweight, teen motherhood, child
          abuse and neglect, and school dropouts are high.  The cost to the
          nation of low birthweight babies in neonatal intensive care is
 
 
                                         13
 
 
 
 
          $1.5 billion annually.#4  The combined Aid to Families With
          Dependent Children, Medicaid, and Food Stamps cost in 1988 for
          families in which the first birth occurred when the mother was a
          teen was estimated at $19.83 billion.#5  The immediate, first-
          year public costs of new reported child abuse cases in 1983 were
          estimated at $487 million for medical care, special education,
          and foster care,#6 and since then the number of child
          maltreatment cases reported has gone up by 47 percent.  Recent
          estimates suggest that each year's high school dropout "class"
          will cost the nation more than $240 billion in lost earnings and
          forgone taxes.#7
 
          Early intervention can save money.  For example, for most
          American families, a child's measles inoculation is considered a
          standard part of well-child care.  But forgoing such
          immunizations--which is happening more frequently--has costly
          consequences.  Lifetime institutional care for a child left
          retarded by measles is between $500,000 and $1 million.
          Researchers have reported the potential of this and other early
          intervention strategies to save money, as shown in table 1.1.
          Experts believe that home visiting can be a key mechanism for
          reaching families early with the preventive services they need.
 
          Table 1.1:  Early Intervention Saves Money
 
          Every $1 spent on:            Saves....
          ------------------            ---------
          The federal Childhood         $10 in later
          Immunization Program          medical costs.(1)
 
          Prenatal care                 $3.38 in later medical costs
                                        for low birthweight infants.(2)
 
          Preschool Education           $3-6 in later remedial education,
                                        welfare, and crime control.(3)
 
 
 

         4"Special Report:  Perinatal Issues 1989," American Hospital
          Association, Chicago (1989), p. 2.
 
         5"Teenage Pregnancy and Too-Early Childbearing:  Public Costs,
          Personal Consequences," Center for Population Options,
          Washington, D.C. (1989), p. 3.
 
         6Deborah Daro, Confronting Child Abuse: Research for Effective
          Program Design, The Free Press, New York (1988), pp. 155-57.
 
         7Children in Need:  Investment Strategies for the Educationally
          Disadvantaged, The Committee for Economic Development, New York
          (1987), p. 3.
 
                                         14
 
 
 
 
          Sources:
 
          1. University of North Carolina Child Health Outcomes Project,
          Monitoring the Health of America's Children, Sept. 1984.
 
          2. Institute of Medicine, Preventing Low Birthweight
          (Washington, D.C.:  National Academy Press, 1985).
 
          3. John R. Berrueta-Clement and others, Changed Lives:  The
          Effects of the Perry Preschool Program on Youths Through Age 19,
          Monographs of the High/Scope Educational Research Foundation,
          Number 8, The High/Scope Press, 1984.
 
          OBJECTIVES, SCOPE, AND METHODOLOGY
          ----------------------------------
          Our objectives in reporting on home visiting were to determine
 
          -- the scope and nature of existing home-visiting programs in the
             United States and Europe that focus on maternal and child
             health and well-being;
 
          -- the effectiveness of home visiting as a service delivery
             strategy;
 
          -- the factors and strategies critical to designing home visitor
             programs; and
 
          -- program and policy options for the Congress and the
             Departments of Health and Human Services and Education in
             using home visiting as a strategy to improve maternal and
             child health and well-being.
 
          To accomplish our first two objectives, we reviewed the
          literature on home visiting and interviewed experts in the areas
          of medical, social, and education intervention.  In reviewing the
          literature, we especially looked for research-based evaluations
          of home visiting that reported program results and costs.  We
          used this information, along with site visits to programs in the
          United States and Europe that used home visiting as a service
          delivery strategy, to accomplish our third objective--developing
          a framework of key design characteristics.
 
          We identified and discussed seven key design characteristics with
          various home-visiting experts who concurred that these
          characteristics were important for developing and operating
          effective programs.  Through our case studies, we observed these
          design characteristics in operation and subsequently combined
          these seven elements into four to form the basis for our
          framework.
 
          Programs we selected for study were cited, either in the
          literature or by experts, as being successful in meeting their
 
                                         15
 
 
 
 
          objectives.  We did not conduct our own evaluation of the
          effectiveness or impact of these programs or conduct a
          comparative analysis of effectiveness of different service
          delivery strategies, such as home-based versus center-based
          services.  While we identified many service areas that used home
          visiting, including home health care for the chronically ill or
          the elderly, we focused on programs serving families from the
          prenatal period through a child's second birthday.
 
          From a list of 31 programs suggested by experts or the literature
          as being successful in meeting their objectives using home
          visiting, we conducted standardized telephone interviews to
          collect information about program objectives and structure.  We
          judgmentally selected six U.S. programs to provide diversity
          among program characteristics.  Primary selection factors
          included programs
 
          -- with different objectives,
 
          -- operating in urban and rural areas,
 
          -- with different target populations, and
 
          -- using home visitors with different backgrounds (for example,
             nurses, paraprofessionals, lay workers).
 
          In addition, we selected Great Britain and Denmark because of
          their long-standing tradition and experience in using home
          visitors to deliver maternal and child health services.
 
          At each site we interviewed senior program managers, home
          visitors, and their supervisors.  We interviewed representatives
          of other local service providers at five of six U.S. locations.
          In addition, in Great Britain and Denmark, we interviewed
          officials from the National Health Service, local health
          authorities, Great Britain's Health Visitors Association, and a
          Danish member of Parliament.  We also accompanied home visitors
          on their rounds in the United States, Great Britain, and Denmark.
 
          At the federal level, we contacted officials in the Departments
          of Health and Human Services and Education responsible for
          programs using home visiting to improve the health and well-being
          of mothers and young children.  We reviewed agency documents to
          identify programs that have funded home visiting.
 
          We did our work between December 1988 and February 1990 in
          accordance with generally accepted government auditing standards.
          We did not, however, verify program cost information.
 
 
 
 
 
                                         16
 
 
 
 
                                      CHAPTER 2
                                      ---------
                          HOME VISITING IS AN ESTABLISHED
                          -------------------------------
                              SERVICE DELIVERY STRATEGY
                              -------------------------
                              WITH MULTIPLE OBJECTIVES
                              ------------------------
          Home visitors have provided early intervention services in the
          United States and Europe for more than 100 years.  In Great
          Britain and Denmark, home visiting is provided without charge to
          almost all families with young children.  In the United States,
          home visiting is not universally available.  It is conducted on a
          project-by-project basis, by governmental and private
          organizations, primarily targeted to "special needs" families.
          Governmental support for home-visiting is split among many
          agencies and programs.
 
          The federal government's involvement and interest in home
          visiting is apparent from its many programmatic activities,
          recently enacted laws, and proposed legislation.  Many states are
          using project grants and formula funding from recent legislation,
          such as Medicaid, to expand home visiting in their states.  The
          Congress authorized new home-visiting demonstration grants in the
          101st Congress, although it did not appropriate funds.  Despite
          such initiatives, we found only limited information exchange
          about home visiting experiences across program lines.
 
          HOME VISITING WIDESPREAD IN EUROPE
          ----------------------------------
          Home visiting is a common part of Western European maternity
          care.#8  Home visitors may be midwives, but most often are
          specially trained nurses.  Usually women are visited at home
          after a child's birth (postpartum).  Nine European countries
          provide prenatal and/or postpartum home visiting either routinely
          or for special indications, such as clinic nonattendance. (See
          table 2.1.)  Seven countries routinely provide at least one
          postpartum home visit.
 
 
 
 
 
 
 
 
 
 
 
 
         8C. Arden Miller, M.D., Maternal Health and Infant Survival,
          National Center for Clinical Infant Programs, Washington, D.C. (1987).
 
                                         17
 
 
 
          Table 2.1:  Home Visiting in Nine Western European Countries
 
          Country                       Prenatal            Postpartum
          -------                       --------            ----------
          Belgium                            Xa                  X
          Denmark                            Xa                  Xb
          Germany                            O                   O
          Great Britain                      O                   X
          France                             O                   O
          Ireland                            O                   X
          Netherlands                        X                   X
          Norway                             O                   X
          Switzerland                        O                   X
 
          Legend:
 
          X  Home visiting is provided at least once for all pregnant women
             or new mothers.
 
          O  Home visiting is provided under special circumstances, such as
             follow-up for a woman not attending prenatal clinic.
 
         aUnevenly implemented.
 
         bIn municipalities that have home visitors (94 percent of all
          Danish municipalities).
 
          Source:  C. Arden Miller, M.D., Maternal Health and Infant
          Survival.
 
          In the two European countries that we visited, Great Britain and
          Denmark, home visiting is a main source of preventive health
          information and care for young children.  It began, however, as a
          way to reduce infant mortality.
 
          Home visiting was begun in Great Britain in 1852 by a local
          voluntary group in Manchester and Salford.  In 1890, Manchester
          became the first locality to employ a home visitor.  By 1905, 50
          areas employed home visitors.  When Great Britain created the
          National Health Service in 1948, home visitors were included as a
          profession.  Today home visitors serve all British families with
          young children.
 
          Home visiting in Denmark started as a pilot program in 1932 and
          was established by law in 1937.  Although the service has always
          been optional, nearly every township has a nurse home-visiting
          program today.  Ninety percent of all Danish infants live in
          counties served by home visitors.
 
          Home visiting in Great Britain and Denmark is provided free of
          charge as a publicly supported service to families with young
          children regardless of family income.  It is an established part
          of preventive health services in national health care systems to
 
                                         18
 
 
 
          which all citizens have access.  Home visitors teach parents good
          health practices and provide preventive health services and
          medical screenings to infants and children directly in their
          homes.  In Great Britain, home visitors meet mothers-to-be at the
          clinic, and then follow the child after birth--through both in-
          home and clinic visits--until the child reaches school age.  In
          Denmark, home visitors begin visiting the family soon after a
          child is born and visit each child several times during the first
          year.
 
          Universal home visiting has certain benefits.  Such an approach
          can attract wider political acceptance with no stigma attached to
          receiving the services.  In the opinion of public health
          officials in Denmark and Great Britain, home visiting promotes
          good health practices and has become an important part of
          preventive health care in their countries. However, neither
          country has a system to evaluate home-visiting program benefits.
 
          Both Great Britain's and Denmark's home-visiting programs are
          facing change.  Great Britain is reexamining its health service,
          with an eye to making it more effective and economical. As a
          result, British local health authorities are beginning to develop
          local measures of home-visiting effectiveness.  Because of a
          shortage of home visitors, local health authorities are beginning
          to target their services more closely to local needs and to at-
          risk families.  Health officials believe that in the future, home
          visitors will visit each family in home at least once, but
          reserve follow-up and more intensive in-home service to families
          they deem at risk.  Low-risk families will be followed in the
          clinic.  Denmark is reviewing its health service and may require
          each county to make home-visiting services available.  However,
          Denmark may also begin charging fees for home-visiting services.
 
          U.S. HOME VISITING TARGETED TO LOW-INCOME AND SPECIAL NEEDS
          -----------------------------------------------------------
          FAMILIES
          --------
          Home visiting in the United States had a similar beginning to
          that in Great Britain and Denmark, but its development has been
          much less systematic and uniform.  Nevertheless, many local
          public and private agencies provide home visiting.  Compared to
          Europe, U.S. programs that provide home visiting are diverse in
          their goals and are likely to be targeted to families with
          special needs, such as families with handicapped children or
          children not developing normally.
 
          Home visiting began in the United States during the 19th century
          to improve the health and welfare of the poor.  In 1858, well-to-
          do volunteers became "Friendly Visitors" to poor families in
          Philadelphia, and the movement later spread to other large
 
 
 
 
                                         19
 
 
 
 
          Eastern cities. In the early 20th century, settlement houses#9
          began to send visiting nurses, teachers, and social workers into
          poor families' homes to provide education, preventive health
          care, and acute care.  This effort was initially fueled by a
          growing awareness that prenatal care and proper infant care could
          improve the survival of infants.  Visiting nurse programs evolved
          from these beginnings.  During the 1970s, home visiting to
          improve low-income children's school readiness was encouraged
          through Head Start#10 demonstration projects.  Today Head Start,
          although primarily a center-based program, administers one of the
          largest home-visiting programs for low-income families in the
          United States, serving over 35,000 children yearly.
 
          Targeted Programs With Diverse Goals
          ------------------------------------
          Many programs in the United States use home visiting to provide
          health, social, or educational services to certain families.
          Programs using home visiting are generally targeted to families
          with special needs, such as those with developmentally delayed
          children or abused children.  These programs provide specialized
          services depending on the program focus and families' needs.
 
          Very limited data are available to quantify the number of
          programs using home visiting.  However, two researchers, Richard
          Roberts and Barbara Wasik, have recently attempted to develop the
          first comprehensive picture of such programs.#11  In 1988, they
          surveyed over 4,500 programs in the United States that appeared
          to use home visiting as a service delivery technique.  Of the
          1,900 programs for which they obtained detailed data, 76 percent
          were targeted toward families with particular problems, such as
          abusive parents or parents with physically handicapped children.
          One-third of the programs served children in the 0-3-year-old
          range.
 
          Unlike in Europe, where preventive health care is the main
          purpose,  Roberts and Wasik found that in the United States, many
          home-visiting programs focus on education or social services.
          Only a third of the programs responding listed health as the
 
 
         9Community centers established in poor urban neighborhoods where
          trained workers tried to improve social conditions by providing
          such services as kindergartens and athletic clubs.
 
        10A national program providing comprehensive developmental
          services, including educational, health, and social services,
          primarily to low-income preschool children age 3 to 5 and their
          families.
 
        11Barbara Hanna Wasik and Richard N. Roberts, "Home Visiting
          Programs for Low-Income Families," Family Resource Coalition
          Report, No. 1 (1989).
 
                                         20
 
 
 
 
          primary focus. Overall, 43 percent of the responding programs
          were either education or Head Start programs.
 
          Only 22 percent of the programs targeted to low-income families
          served expectant families before birth and children up to age 3,
          compared with 43 percent of programs not specifically targeted to
          low-income families.  Head Start programs represented 45 percent
          of programs targeted specifically to low-income families.
          However, Head Start primarily serves children age 3 to 5 years.
 
          FUNDING FOR U.S. HOME VISITING FROM MULTIPLE AGENCIES
          -----------------------------------------------------
          Federal and state governments support home visiting through many
          programs, with both one-time project funds and ongoing funding
          sources.  We could not determine the full extent of federal
          funding for home visiting, because federal managers we
          interviewed did not know the extent to which states were using
          federal monies to fund home visiting.  Federal managers were not
          always aware of results of effective programs funded by other
          agencies, the materials developed, or of state efforts in home
          visiting.
 
          The Departments of Health and Human Services and Education have
          provided funds for home visiting to families with young children
          through various programs and through both project and formula
          grants. (See table 2.2.)  Project grants are given directly to
          public or private agencies to finance specific projects, such as
          developing model programs.  Formula grants are given to states,
          their subdivisions, or other recipients according to a formula
          (usually related to population) for continuing activities not
          confined to a specific project.  States often have to match
          federal formula grant funds with state-contributed funds.
 
 
 
 
                                         21
 
 
 
 
          Table 2.2:  Federal Programs Used to Fund Home Visitor Projects#a
 
          Agency             Office              Program                Type
          ------             ------              -------                ----
          Department of Health and Human Services
          ---------------------------------------
          Office of          Head Start          Home-Based             Project
          Human                                  Head Start             grant
          Development
          Services/          Head Start          Parent Child           Project
          Administration                         Centers                grant
          for Children,
          Youth, and         Head Start          Comprehensive          Project
          Families                               Child                  grant
                                                 Development
                                                 Centers
 
                             National Center     Child Abuse and        Formula
                             on Child Abuse      Neglect                grant
                             and Neglect         "Challenge"
                                                 Grants
 
                             National Center     Child Abuse and        Project
                             on Child Abuse      Neglect Research       grant
                             and Neglect         and Demonstration
                                                 Grants
 
          Public             Maternal            Maternal and           Formula
          Health             and Child           Child Health           grant
          Service            Health and          Services Block
                             Resources           Grant
                             Development
 
                             Maternal            Special Projects       Project
                             and Child           of Regional and        grant
                             Health and          National
                             Resources           Significance
                             Development         (SPRANS)#b
 
          Health             Bureau of           Medicaid               Formula
          Care               Program                                    grant#c
          Financing          Operations
          Administration
 
          Department of Education
          -----------------------
          Office of                              Education of the       Formula
          Special                                Handicapped Act        grant
          Education                              Part B & H
          Programs                               Programs
 
 
 
                                                 22
 
 
 
 
                                                 Chapter 1              Formula
                                                 Handicapped            grant
                                                 Program#d
 
                                                 Handicapped            Project
                                                 Children's Early       grant
                                                 Education Program
 
         aHome visiting may be funded by other federal programs not
          identified by GAO and not listed here.
 
         bThese projects are funded by a federal set-aside of 10 to 15
          percent of the Maternal and Child Health Block Grant
          appropriation.
 
         cMedicaid is a joint federal-state program that entitles eligible
          persons to covered medical services.  The federal government
          matches state payments to providers and administrative costs
          using a formula based on state per capita income.
 
         dThe Chapter 1 Handicapped Programs of the Education
          Consolidation and Improvement Act of 1981 provide grants to
          states to expand or improve educational services to handicapped
          children.
 
          States have supported home visiting through their use of both
          federally funded formula grants and state funds.  For example:
 
          -- Tennessee, Michigan, and Delaware have used federal child
             abuse and neglect "challenge" grant funds to support home-
             visiting programs.
 
          -- Hawaii has used both state funds and Maternal and Child Health
             Services (MCH) block grant#12 funds to expand to more sites a
             home-visiting program to prevent child abuse and neglect.
 
          -- Missouri has funded a universal, educational home-visiting
             program, "Parents as Teachers," using state education funds.
 
          -- Maine is trying to establish public health nurse home visiting
             for every newborn, using state public health funds and MCH
             block grant funds.
 
          The Departments of Health and Human Services (HHS) and Education
          did not know the full amount of federal funds spent for early
          intervention services for children who are handicapped,
 
 
        12The MCH block grant is a federal formula grant awarded annually
          to state health agencies to assure access to quality maternal and
          child health services, reduce infant mortality and morbidity, and
          provide assistance to children needing special health services.
 
                                         23
 
 
 
 
          developmentally delayed, or at risk of developmental delay.
          Also, most federal managers we contacted could not tell us the
          amount of funding their programs were providing for home visiting
          as an early intervention service delivery for at-risk children.
          Managers at the federal level could provide examples of federally
          funded demonstration programs that used home visiting, but were
          not sure of the extent to which states were using formula grants
          to fund home visiting.  Clearly, many sources of federal support
          for home visiting are available.  But overall funding
          information is limited.  With the exception of Home-Based Head
          Start, home visiting has never been the primary focus of any
          federal programs.
 
          Despite this federal and state commitment to home visiting, we
          found only limited information exchange about home visiting
          across program lines.  For example, Head Start has developed
          materials for home visitors, including The Head Start Home
          Visitor Handbook and A Guide for Operating a Home-Based Child
          Development Program.  However, some program officials in other
          HHS agencies were not aware that these guides existed and thus
          could not share them with projects they were supervising.
 
          Some federal officials did not know that states were providing
          home visiting using federal formula funds.  Health Care Financing
          Administration officials we contacted who manage the Medicaid
          program were not aware that some states were providing preventive
          prenatal services in the home as part of the state Medicaid
          program.
 
          Some of the clearinghouses funded by federal agencies that have
          supported home visiting cannot readily provide information on
          that topic. The Education Resources Information Center, a
          clearinghouse that the Department of Education supports, was able
          to identify resource materials on home visiting.  However, two
          HHS-funded clearinghouses, the National Maternal and Child
          Health Clearinghouse and the Clearinghouse on Child Abuse and
          Neglect Information, could not readily identify resource
          materials on home visiting to improve maternal and child health
          outcomes or to prevent abuse and neglect.
 
          NEW IMPETUS FOR HOME VISITING FROM RECENT LEGISLATION
          -----------------------------------------------------
          Several recently enacted laws include provisions that may
          encourage home visiting.  The Education of the Handicapped Act
          Amendments of 1986, recent Medicaid prenatal care expansions, and
          the 1988 Child Abuse Prevention, Adoption, and Family Services
          Act provide options for states to fund home visiting.  Recently
          introduced bills also contain provisions to encourage home
          visiting through earmarked program funds and through additional
          Medicaid changes.
 
 
 
                                         24
 
 
 
 
          Public Law 99-457 May Broaden Availability of Home Visiting
          -----------------------------------------------------------
          The Education of the Handicapped Act Amendments of 1986, Public
          Law 99-457, may further encourage home visiting.  Through the
          addition of Part H, the statute authorized financial assistance
          to assist states in developing and implementing statewide,
          comprehensive early intervention services for developmentally
          delayed and at-risk infants and toddlers and their families.  The
          legislation extended program benefits to children aged birth
          through 2 years in states choosing to participate.  The
          Department of Education has indicated that home visiting, while
          optional, is among the minimum services that should be provided
          to eligible children.
 
          States must serve a core group of developmentally delayed
          children, but at their discretion can also serve children who are
          at risk of developmental delay.  Developmental delay includes
          delays in one or more of the following areas:  cognitive
          development, physical development, language and speech
          development, psychosocial development, and self-help skills.
          Children with a diagnosed physical or mental condition that has
          a high probability of resulting in developmental delay are also
          eligible.  Children can be classed as "at risk" due to either
          environmental or biological risk factors.  Environmental risk
          factors for children could include poverty, having a teen parent,
          or being homeless.  The legislation gives states flexibility in
          defining developmental delay and setting eligibility and service
          delivery standards.  However, once the standard is set, all
          children in the state who are eligible are entitled to services.
          State programs must be in place and serving all eligible children
          by a state's fifth year of participation, which could be as early
          as July 1991 for states that have participated in the program
          continuously since its inception in fiscal year 1987.
 
          To help mobilize resources and facilitate state implementation of
          Public Law 99-457, agencies within the Department of Education
          and HHS created the Federal Interagency Coordinating Council
          (FICC).  FICC's mission is to develop specific action steps that
          promote a coordinated, interagency approach to sharing
          information and resources in five areas: (1) regulations, program
          guidance, and priorities; (2) parent participation; (3)
          identification of children needing services; (4) materials and
          resources; and (5) training and technical assistance.  (See table
          2.3 for participating agencies.)  FICC-supported activities
          include an annual Partnerships for Progress conference, which has
          been used to disseminate information to state officials on
          innovative programs as well as on funding sources that can be
          used to pay for services.  Another joint project was the
          development and distribution of a reference book for schools
          attended by children who are dependent on medical technology,
          such as children who need regular renal dialysis.  The Bureau of
          Maternal and Child Health and Resources Development and
 
                                         25
 
 
 
          representatives of FICC also sponsored a February 1988 conference
          and subsequent publication, Family Support in the Home: Home
          Visiting Programs and P.L. 99-457, to provide guidelines and
          recommendations for using home visiting as a service delivery
          mechanism under the statute.
 
          Table 2.3:  Signatories to the FICC Memorandum of Understanding
 
                                         Signatories
                            -----------------------------------------------
          Department        Principal                  Other
          ----------        ---------                  -----
          Education         Assistant Secretary,       Director,
                            Office of Special          Office of Special
                            Education and              Education Programs
                            Rehabilitative Services
                                                       Director,
                                                       National Institute
                                                       on Disability and
                                                       Rehabilitation
                                                       Research
 
          HHS               Assistant Secretary,       Commissioner,
                            Office of Human            Administration for
                            Development Services       Children, Youth and
                                                       Families
 
                                                       Commissioner,
                                                       Administration on
                                                       Developmental
                                                       Disabilities
 
                            Assistant Secretary        Director,
                            for Health                 National Institute
                                                       on Mental Health
 
                                                       Administrator,
                                                       Health Resources and
                                                       Services
                                                       Administration
 
                                                       Director,
                                                       Bureau of Maternal
                                                       and Child Health and
                                                       Resources
                                                       Development
 
                                                       Director,
                                                       Office of the
                                                       Associate Director
                                                       for Maternal and
                                                       Child Health
 
 
                                         26
 
 
 
 
                            Administrator,
                            Health Care
                            Financing Administration
 
          States Are Using Medicaid to Fund Home Visiting
          -----------------------------------------------
          Medicaid has become a more significant source of funding for pre-
          and postnatal services as Medicaid eligibility has expanded to
          cover more low-income women.  Beginning with the Deficit
          Reduction Act of 1984, the Congress expanded Medicaid coverage of
          pregnant women and children, primarily by severing the link
          between eligibility for Medicaid and Aid to Families With
          Dependent Children (AFDC).#13  As of April 1, 1990, states are
          required to cover pregnant women and children up to age 6 with
          family income up to 133 percent of the federal poverty level.  At
          their option, states can also cover children up to age 8 with
          income up to 133 percent of federal poverty and pregnant women
          and infants up to age 1 with family income from 133 percent to
          185 percent of the federal poverty level.
 
          In states that allow Medicaid payment for home visiting, Medicaid
          can serve as an ongoing funding source.  The Consolidated Omnibus
          Budget Reconciliation Act of 1985 permits states to obtain
          federal matching funds when offering more extensive or "enhanced"
          prenatal care services to low-income pregnant women.  These kinds
          of services do not have to be made available to other Medicaid
          recipients.  States may add case management and extra prenatal
          care services by amending their state plans.  While home visiting
          is not specifically listed as a covered Medicaid service, some
          states have used their authority under the 1985 act to obtain
          reimbursement for in-home case management services or other in-
          home services to certain pregnant women.  New Jersey, for
          example, requires at least one prenatal and postpartum home visit
          for high-risk women being served through its Medicaid-funded
          enhanced prenatal care program.  According to the National
          Governors' Association and the National Commission to Prevent
 
 
 
 
 
 
        13Medicaid eligibility for pregnant women and children had been
          linked to actual or potential receipt of cash assistance under
          the AFDC program or the Supplemental Security Income program.  To
          be eligible for these programs, income and assets cannot be above
          specified levels.  On average across the states, a family's
          annual income in 1989 had to fall below 48 percent of the federal
          poverty level to qualify for AFDC, with income limits ranging
          from 14.0 percent ($1,416 for a family of three) in Alabama to
          79.0 percent ($7,956) in California.  The 1989 federal poverty
          level for a family of three was $10,060.
 
                                         27
 
 
 
          Infant Mortality, as of February 1990, 24 states#14 were using
          Medicaid to pay pre- and/or postnatal care providers for home
          visiting.
 
          Home Visiting Is Encouraged to Prevent Child Abuse and Neglect
          --------------------------------------------------------------
          The Child Abuse Prevention, Adoption, and Family Services Act of
          1988 recognized home visiting as an appropriate strategy for
          preventing child abuse and neglect.  This act focused federal
          efforts to aid states and localities in preventing child abuse as
          well as intervening once abuse had occurred.  The legislation
          reauthorized a state formula grant program that "challenges"
          states to establish earmarked funding for child abuse and neglect
          prevention programs by providing a 25-percent federal dollar
          match.  States have used challenge grant monies to support home-
          visiting services.
 
          Increased Interest in Home Visiting in Recent Legislative
          ---------------------------------------------------------
          Proposals
          ---------
          Several legislative proposals that addressed home visiting were
          introduced in the 101st Congress:
 
          -- The Healthy Birth Act of 1989 (H.R. 1710 and S. 708) proposed
             an increased authorization of $100 million to the MCH block
             grant program to fund various additional projects, including
             home visiting.
 
          -- The Maternal and Child Health Improvement Act of 1989 (H.R.
             1584) proposed an increased authorization of $50 million for
             the MCH block grant program, to be used partially for home
             visiting.
 
          -- The Maternal and Child Health Block Grant Amendments of 1989
             (H.R. 2651) proposed an increased authorization of $100
             million for the MCH block grant program, with a set-aside to
             fund home visiting demonstrations.
 
          -- The Child Investment and Security Act of 1989 (H.R. 1573)
             proposed to require Medicaid coverage of prenatal and
             postpartum home-visiting services.
 
          -- The Omnibus Budget Reconciliation Act of 1989 (H.R. 2924), The
             Infant Mortality Amendments of 1990 (S. 2198), and The
             Medicaid Infant Mortality Amendments of 1990 (H.R. 3931)
             proposed that prenatal home-visiting services for high-risk
 
 
        14Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware,
          Idaho, Kansas, Maryland, Michigan, Minnesota, Mississippi, New
          Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon,
          Pennsylvania, Tennessee, Utah, Vermont, Virginia, and Washington.
 
                                         28
 
 
 
 
             pregnant women and postpartum home-visiting services for high-
             risk infants up to age 1 be made optional Medicaid services.
 
          The Congressional Budget Office estimated that if home visiting
          was made an optional Medicaid service, as proposed in H.R. 2924,
          the additional federal Medicaid cost would be $95 million over a
          5-year period for fiscal years 1990-94.  If the services were
          mandatory, as was proposed in H.R. 1573, the estimated additional
          5-year federal cost could go up to $625 million.
 
          None of this legislation was passed as introduced, as of June
          1990.  However, the Congress did authorize, through the Omnibus
          Budget Reconciliation Act of 1989 (Public Law 101-239), new home-
          visiting demonstration projects to be funded through a set-aside
          from the MCH block grant when its funding level exceeds $600
          million (currently at $561 million).
 

 
                                         29
 
 
 
                                      CHAPTER 3
                                      ---------
                   HOME-VISITING EVALUATIONS DEMONSTRATE BENEFITS,
                   -----------------------------------------------
                              BUT SOME QUESTIONS REMAIN
                              -------------------------
          Evaluations of early intervention programs using home visiting
          have shown that children and their families had improved health
          and well-being, compared to families who did not receive
          services.  This was particularly true for families who are among
          groups that often face barriers to needed care, such as
          adolescent mothers, low-income families, and families living in
          rural areas.  In a few cases where follow-up studies were done on
          programs that combined home and center-based services, these
          salutary effects persisted over time as children developed.  More
          intensive services seemed to produce the strongest effects.  But
          few experimental research initiatives have compared home visiting
          to other strategies for delivering early intervention services.
 
          Cost data, while limited, indicate that providing home-visiting
          services for at-risk families can be less costly than paying for
          the consequences of the poor outcomes associated with delayed or
          no care.  Evaluations have also not adequately addressed whether
          home visiting is more costly than providing similar services in
          other settings.
 
          PROGRAM EVALUATIONS SHOW BENEFITS OF HOME VISITING
          --------------------------------------------------
          Evaluations of early intervention programs that used home
          visiting show that this strategy can be associated with a variety
          of improved outcomes for program participants--improved birth
          outcomes, better child health, improved child welfare, and
          improved development--when compared to similar individuals who
          did not receive services.  In addition to being at risk for
          adverse outcomes, the target population for these programs often
          belonged to groups that experience difficulty accessing needed
          services.
 
          Examples of improved outcomes associated with home visiting
          include the following:
 
          -- Pregnant adolescents in rural areas visited by the South
             Carolina Resource Mothers Program had half the percentage of
             small-for-gestational-age infants and significantly fewer low
             birthweight babies compared to a similar group of pregnant
             adolescents in a rural county without such a program.#15
 
 
 
 
        15Henry C. Heins, Jr., and others, "Social Support in Improving
          Perinatal Outcome: The Resource Mothers Program," Obstetrics and
          Gynecology, Vol. 70, No. 2 (Aug. 1987).
 
                                         30
 
 
 
 
          -- Low-income mothers visited in Michigan gave birth to babies
             with significantly improved birthweight and health at birth,
             compared to both their previous pregnancies and to a control
             group with similar demographic characteristics.#16
 
          -- Children in working class families randomly assigned to a
             group that received home-visiting services had significantly
             fewer accidents in their first year and had a better rate of
             immunizations than children who were not visited.  The home
             visiting was more successful when it began prenatally.#17
 
          -- For several home-visiting projects, participants had a lower
             reported incidence of child abuse and neglect than that found
             in similar families.#18
 
          Children at risk of developmental delay have also benefited from
          services delivered through home visiting.  Premature low
          birthweight babies and malnourished children whose families were
          seen by home visitors were able to physically and developmentally
          "catch up" to their healthier peers.#19  For example:
 
          -- Fewer low birthweight children in a Florida program needed
             additional developmental services after graduating from a
 
 
 
        16Jeffrey P. Mayer, "Evaluation of Maternal and Child Health
          Community Nursing Services: Application of Two Quasi-Experimental
          Designs," Health Action Papers, Vol. 2 (1988).
 
        17Charles P. Larson, "Efficacy of Prenatal and Postpartum Home
          Visits on Child Health and Development," Pediatrics, Vol. 66,
          No. 2 (Aug. 1980).
 
        18U.S. Congress, Office of Technology Assessment, Healthy
          Children: Investing in the Future, OTA-H-345 (Washington, D.C.:
          U.S. Government Printing Office, Feb. 1988); Deborah Daro,
          Confronting Child Abuse: Research for Effective Program Design,
          The Free Press, New York, 1988.
 
        19Tiffany M. Field and others, "Teenage, Lower-Class, Black
          Mothers and Their Preterm Infants: An Intervention and
          Developmental Follow-up," Child Development, Vol. 51 (1980);
          Virginia Rauh and others, "Minimizing Adverse Effects of Low
          Birthweight: Four-Year Results of an Early Intervention Program,"
          Child Development, Vol. 59, (1988); Gail S. Ross, "Home
          Intervention for Premature Infants of Low-Income Families,
          "American Journal of Orthopsychiatry, Vol. 54, No. 2 (Apr. 1984).
 
 
 
 
 
                                         31
 
 
 
 
             randomly assigned 2-year home-visiting program compared to
             children who received no services.#20
 
          -- Three years after the program ended, children in Jamaica who
             were home visited to help them overcome the effects of
             malnutrition had significantly higher IQ scores than
             malnourished children with similar medical and demographic
             characteristics who had not received services.#21
 
          Other programs have also found significant improvements in the
          cognitive ability of rural and inner-city children who had been
          provided with preschool services through home visiting, compared
          to children who were not provided with such services.#22
 
          Benefits to Families Can Persist Over Time
          ------------------------------------------
          The full effects of early intervention programs using home
          visiting as part of their service delivery can become more
          impressive as parents use what they have been taught and children
          grow and further develop.  Such contact during a child's early
          years often results in improved family functioning, better school
          performance, and better outcomes after high school.  We
          identified several programs with longitudinal evaluations that
          had provided both center- and home-based services.
 
          From 1962 to 1967, the High/Scope Perry Preschool Program, in
          Ypsilanti, Michigan, provided both weekly home visits for the
          parents of low-income, 3- and 4-year-olds and comprehensive
          center-based preschool services for the children.  Children from
          the families who agreed to participate were randomly assigned to
          either a group that received preschool and home visiting or a
          control group.  Participants scored significantly higher on tests
          of intellectual ability after 1 year in the program and did
          better on standardized testing through the middle grades, than
 
 
        20Michael B. Resnick and others, "Developmental Intervention for
          Low Birth Weight Infants:  Improved Early Developmental
          Outcomes," Pediatrics, Vol. 80, No. 1 (July 1987).
 
        21Sally Grantham-McGregor and others, "Development of Severely
          Malnourished Children Who Received Psychosocial Stimulation: Six
          Year Follow-up," Pediatrics, Vol. 79, No. 2 (Feb. 1987).
 
        22Donna M. Bryant and Craig T. Ramey, "An Analysis of the
          Effectiveness of Early Intervention Programs for Environmentally
          At-Risk Children," in The Effectiveness of Early Intervention for
          At-Risk and Handicapped Children, ed. Michael J. Guralnick and
          Forrest C. Bennett, Academic Press, Inc. Orlando (1987); Charles
          W. Burkett, "Effects of Frequency of Home Visits on Achievement
          of Preschool Students in a Home-Based Early Childhood Education
          Program," Journal of Educational Research, Vol 76, No. 1 (Oct. 1982).
 
                                         32
 
 
 
 
          did the control children.  At age 15, they placed a higher value
          on schooling.
 
          For many of these children, early school success served as a
          preparation for greater life success.  At age 19, young people
          who had participated in the program were more likely to be
          literate and employed or in college.  They were less likely to
          have dropped out of school, to be on welfare, or to have been
          arrested.#23  (See fig. 3.1.)  One reviewer looking at the
          effects of preschool pointed to the High/Scope Perry Preschool's
          home visiting as being a significant factor in its success.#24
 
 
 
        23Lawrence J. Schweinhart and David B. Weikart, "The High/Scope
          Perry Preschool Program," in 14 Ounces of Prevention: A Casebook
          for Practitioners, Richard H. Price and others, ed., American
          Psychological Association, Washington, D.C. (1988).
 
        24Ron Haskins, "Beyond Metaphor: The Efficacy of Early Childhood
          Education," American Psychologist, Vol 44, No. 2 (Feb. 1989).
 
 
                                         33
 
 
 
 
          Figure 3.1:  Students Receiving Preschool and Home-Visiting
          Services Were More Successful in Later Years
 
           (Could not be reproduced for electronic viewing.)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
          Note:  Results show comparative outcomes at age 19 for High/Scope
          Perry Preschool children compared to the randomly selected
          control group.
 
          The Yale Child Welfare Research Program also had impressive
          results over time.  A group of 17 families received home visiting
          along with developmental day care and close pediatric
          supervision.  The control group, chosen the following year, was
          another group of families with similar characteristics who did
          not receive program services.  Ten years later, more home-visited
          families than control group families were employed and had moved
          to improved housing.  Their children were doing better in school.
          Teachers rated the program-participating children as better
 
 
 
 
 
 
 
                                         34
 
 
 
 
          adapted socially and needing fewer remedial school services than
          the control children.#25
 
          Intense Programs Have More Marked Effects
          -----------------------------------------
          Evaluations of early intervention programs using home visiting
          and varying in service intensity--the amount of program contact
          with clients over time--found that more intense programs are
          generally more effective.
 
          An evaluation of a program in Jamaica that provided home-visiting
          services to improve low-income children's cognitive development
          found that children who were visited weekly showed the most
          marked improvement in development, compared to children who were
          randomly assigned to receive less frequent or no services.
          Children visited every 2 weeks also showed significant
          improvement in cognitive development, but not as great as those
          visited weekly.  The children visited monthly showed a similar
          developmental pattern to the children receiving no services.#26
 
          Intensive home visiting, in conjunction with medical and
          educational interventions, has proven effective at keeping IQ
          scores of groups of randomly assigned disadvantaged children from
          dropping over time, compared to those of control groups.  A
          comparative evaluation of 17 programs, 11 of which used home
          visiting, showed that program effectiveness increased as other
          services were combined with home visiting. Two of the three most
          effective and most intensive programs used home visiting in
          addition to center-based services.#27
 
          The Brookline, Massachusetts, Early Education Project is an
          example of home visiting as a crucial service component for
          reaching disadvantaged families.  This experimental program
          randomly assigned recruited families to varying levels of drop-
          in, child care, and home-visiting services provided from infancy
          through the preschool years.  Children of mothers who had not
          graduated from college and who received only center-based
 
 
        25Victoria Seitz and others, "Effects of Family Support
          Intervention: A Ten-Year Follow-up," Child Development, Vol. 56
          (1985).
 
        26Christine Powell and Sally Grantham-McGregor, "Home Visiting of
          Varying Frequency and Child Development," Pediatrics, Vol. 84,
          No. 1 (July 1989).
 
        27Donna M. Bryant and Craig T. Ramey, "An Analysis of the
          Effectiveness of Early Intervention Programs for Environmentally
          At-Risk Children," in The Effectiveness of Early Intervention For
          At-Risk and Handicapped Children, Michael J. Guralnick and
          Forrest C. Bennett, ed., Academic Press, Inc. (1987).
 
                                         35
 
 
 
 
          services were almost twice as likely to have reading difficulties
          in second grade as similar children who had received both home-
          and center-based services.#28  (See fig. 3.2.)
 
          Figure 3.2:  Type and Amount of Services Affect Later Reading
          Ability
 
           (Could not be reproduced for electronic viewing.)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
          Source:  "The Brookline Early Education Project," Donald E.
          Pierson in 14 Ounces of Prevention:  A Casebook for
          Practitioners, Richard H. Price and others, American
          Psychological Association, Washington, D.C. (1988).
 
 
 
 
 
 
        28Donald E. Pierson, "The Brookline Early Education Project," in
          14 Ounces of Prevention:  A Casebook for Practitioners, Richard
          H. Price and others, ed., American Psychological Association,
          Washington, D.C. (1988).
 
                                         36
 
 
 
          RESEARCH SHOWS HOME VISITING COMPARED TO OTHER STRATEGIES IS
          ------------------------------------------------------------
          PROMISING, BUT MORE STUDY IS NEEDED
          -----------------------------------
          Whether one early intervention strategy is more effective than
          another is difficult to determine from the literature because few
          programs were developed and operated as part of a controlled
          experiment or quasi-experiment.  Many programs demonstrating
          benefits to clients delivered both in-home and center-based
          services, but did not try to determine which had the greater
          impact or which was the most cost-effective.  We identified two
          comparative studies that examined the differential effects of
          early intervention service delivery strategies.
 
          Beginning in 1978, Elmira, New York, was the site of a major and
          often-cited research experiment using home visitors as a service
          delivery strategy.  First-time mothers, particularly teenage,
          single, or poor mothers, were recruited for the program and then
          randomly assigned to one of four treatments: (1) no program
          services during pregnancy, (2) free transportation to prenatal
          care and well-baby visits, (3) nurse home visiting during
          pregnancy and transportation services, or (4) nurse home visiting
          during pregnancy and until the child's second birthday, in
          addition to transportation services.  The program had both short-
          and long-term positive effects for the home-visited mothers and
          their children when compared to those receiving only
          transportation to health clinics or no services. The positive
          effects of those visited in the home, compared to the women who
          were not visited, included the following:
 
          -- Higher birthweight babies born to teen mothers and smokers.
 
          -- Fewer kidney infections during pregnancy.
 
          -- Fewer verified cases of child abuse and neglect.
 
          -- Four years later, more months of employment, fewer subsequent
             pregnancies, and postponed birth of second child.#29
 
          A primary reason for using home visitors is to reach families who
          might otherwise not have access to services, such as rural
          families living in isolated areas, or families who might avoid
 
 
        29David L. Olds and others, "Improving the Delivery of Prenatal
          Care and Outcomes of Pregnancy:  A Randomized Trial of Nurse Home
          Visitation," Pediatrics, Vol. 77, No. 1 (Jan. 1986); David L.
          Olds and others, "Preventing Child Abuse and Neglect:  A
          Randomized Trial of Nurse Home Visitation," Pediatrics, Vol. 78,
          No. 1 (July 1986); David L. Olds and others, "Improving the
          Life-Course Development of Socially Disadvantaged Mothers:  A
          Randomized Trial of Nurse Home Visitation," American Journal of
          Public Health, Vol. 78, No. 11 (Nov. 1988).
 
                                         37
 
 
 
 
          formal service providers, such as abusive families.  Home-Based
          Head Start is an example of a program that provides services
          through home visiting predominantly to rural children who could
          not take advantage of the traditional center-based Head Start
          program.  Although the children were not randomly assigned to the
          two different service delivery strategies, an evaluation of the
          Home-Based Head Start program found that, after statistically
          adjusting for initial group differences, children from home-
          based, center-based, and mixed home- and center-based Head Start
          programs tested equally well in cognitive ability and social
          development following their participation in preschool
          activities.#30
 
          LIMITED RESEARCH SHOWS HOME VISITING CAN PRODUCE COST SAVINGS
          -------------------------------------------------------------
          Evaluations that analyze home visiting's costs and benefits,
          while few in number, have shown that programs incorporating home
          visiting as a service delivery strategy can prevent families from
          needing later, more costly public supportive services.  Cost
          savings become more obvious when examined by longitudinal studies
          or when initial costs for alternate solutions are high.  Whether
          home-based services are more expensive than providing similar
          center-based services depends on a program's objectives,
          services, and type of provider.  Few true cost-effectiveness
          studies have been done.
 
          Of the 72 published evaluations we reviewed that identified the
          effects of home visiting, only 8 discussed program costs and only
          6 had estimates of immediate or future cost savings.  Yet the
          results of these studies are compelling.  They represent
          findings from studies with rigorous experimental or quasi-
          experimental designs, and several are often cited in the early
          intervention literature.
 
          The High/Scope Perry Preschool Program evaluators estimated that
          the program--with its critical home-visiting component--saved
          from $3 to $6 of public funds for every $1 spent.  The total
          savings to taxpayers for the program (in constant 1981 dollars
          discounted at 3 percent annually) were approximately $28,000 per
          program participant.#31  According to the program evaluators,
          taxpayers saved approximately $5,000 in special education, $3,000
          in crime, and $16,000 in welfare expenditures per participant.
          More Perry Preschool graduates enrolled in college or other
          advanced training, which added $1,000 per preschool participant's
 
 
        30John M. Love and others, Study of the Home-Based Option in Head
          Start, RMC Research Corporation, 1988.
 
        31Lawrence J. Schweinhart and David B. Weikart, "The High/Scope
          Perry Preschool Program," in 14 Ounces of Prevention: A Casebook
          for Practitioners.
 
                                         38
 
 
 
 
          costs; but due to anticipated increased lifetime earnings, the
          average preschool participant was expected to pay $5,000 more in
          taxes.
 
          The Yale Child Welfare Research Program also showed significant
          cost savings over time.  Researchers estimated that 15 control
          families cost taxpayers $40,000 more in 1982 in welfare and
          school remediation expenses than did 15 home-visited families in
          a follow-up study conducted 10 years later.  Families in the
          program showed a slow but steady rise in financial independence,
          which translated into reduced subsequent welfare costs.  No
          significant differences were found for girls, but each
          participating boy required, on average, $1,100 less in school
          remedial services than boys in families who had not received
          services.#32
 
          Few Comparisons of Cost-Effectiveness
          -------------------------------------
          Cost-effectiveness analysis evaluates the cost of producing a
          particular outcome using alternative strategies.  But the most
          effective or least costly alternative may not always be the most
          cost-effective.#33  We found only three cost-effectiveness
          analyses of programs that compared home visiting to other
          alternatives.  In one case, providing home visiting was more
          cost-effective than providing longer hospitalization for low
          birthweight infants.  In another case, using paraprofessional
          home visitors in conjunction with professional, center-based
          social work therapy was more effective in treating child-abusing
          families, but also more costly, than providing center-based
          social work therapy alone.  A third case showed that providing
          home-based preschool services cost slightly less per child on
          average than center-based services, but resulted in equal
          outcomes.
 
          The New England Journal of Medicine reported that home visiting
          allowed one Philadelphia hospital to serve low birthweight
          infants more cost-effectively at home than in the hospital.  Low
          birthweight infants were randomly assigned to one of two groups.
          Members of the control group were discharged according to routine
          nursery criteria, which included an infant weight of about 4.8
          lbs.  Those in the experimental group were discharged before
          reaching this weight if they met a standard set of conditions.
          Families of early-discharge infants received individualized
          instruction, counseling, and home visits, and were allowed to
 
 
        32Victoria Seitz and others, "Effects of Family Support
          Intervention: A Ten-Year Follow-up," Child Development.
 
        33Henry M. Levin, Cost-Effectiveness:  A Primer, New
          Perspectives in Evaluation, Volume 4, Sage Publications (1983).
 
 
                                         39
 
 
 
 
          call a hospital-based nurse specialist with any questions for 18
          months.#34
 
          Early hospital discharge did not result in later problems, such
          as increased rehospitalizations, and proved to be more cost-
          effective than keeping infants in the hospital.  The average
          hospital charge for the early discharge group receiving in-home
          services was $47,520 compared to $64,940 for the control group.
          The home-visited infants also experienced a 22-percent reduction-
          -$5,933 versus $7,649--in physicians' costs. Costs for the nurse
          home visits averaged $576 per child, compared to average
          additional overall hospital costs and physician charges of
          $19,136 per child for the comparison group of low birthweight
          infants retained in the hospital.  Since 75 percent of the early
          discharged infants were on Medicaid, the program represented
          considerable public health cost savings.
 
          Another program evaluation studied the cost-effectiveness of
          adding home visiting by nonprofessionals to center-based
          professional social worker therapy to prevent child abuse and
          neglect.  Families identified as abusive or potentially abusive
          were randomly assigned to either professional social work therapy
          services only or a combination of slightly fewer hours of social
          work therapy combined with home visiting.  No families in either
          group were reported for abusing their children while in
          treatment.  Only 26 percent of the home-visited families dropped
          out of treatment during 1 year, compared to 50 percent of the
          families receiving center-based services only.  Overall, the
          home-visited families showed slightly improved outcomes compared
          to the group that received only center-based social work
          services.#35
 
          However, in this case, combining home visiting with center-based
          social work services almost tripled the cost per client (from $93
          to $255 per month).  The increased costs were due to giving the
          home visitors low caseloads (average caseload was 6) and having
          a separate supervisor for the home visitors, rather than letting
          the social workers supervise home visitors.  Program evaluators
          suggested that using nonprofessional home visitors could be more
          cost-effective if the caseloads were increased, full-time home
          visitors were used, and the home visitors were supervised by the
 
 
        34Dorothy Brooten and others, "A Randomized Clinical Trial of
          Early Hospital Discharge and Home Follow-up of Very-Low-Birth-
          Weight Infants," New England Journal of Medicine, Vol. 315 (Oct.
          9, 1986).
 
        35Joseph P. Hornick and Margaret E. Clarke, "A Cost-
          Effectiveness Evaluation of Lay Therapy Treatment for Child
          Abusing and High Risk Parents," Child Abuse and Neglect, Vol. 10
          (1986).
 
                                         40
 
 
 
 
          social workers.  The evaluation did not analyze long-term costs
          or savings, such as the longer term significance of retaining
          more abusive or potentially abusive families in treatment.
 
          While some observers might assume that providing home-based
          services is likely to be more expensive than providing center-
          based services, this is not necessarily so.  Head Start officials
          told us that Home-Based Head Start cost less per child in fiscal
          1988 ($2,429) than did the average 1989 projected Head Start cost
          per child ($2,664).  However, Head Start provides home-based
          services not because they are less expensive, but because they
          bring Head Start to rural children living in isolated areas who
          might otherwise not have access to a preschool program.
 
 
 
 
 
                                        41
 
 
 
                                      CHAPTER 4
                                      ---------
                       POOR PROGRAM DESIGN CAN LIMIT BENEFITS
                       --------------------------------------
                                  OF HOME VISITING
                                  ----------------
          Not all programs using home visiting to deliver services have
          been successful.  Some programs have not measurably improved
          maternal and child health, child welfare, and child development.
          Program evaluators do not always discuss the reasons for program
          failure.  But when they do, the reasons are often tied to
          specific problems in program design and implementation.  By
          analyzing the literature on home-visiting evaluations and
          consulting with home-visiting experts and program managers, we
          identified critical design components that should be considered
          when developing programs that use home visitors.
 
          POOR PROGRAM OUTCOMES LINKED TO DESIGN WEAKNESSES
          -------------------------------------------------
          Some evaluations of programs using home visitors that failed to
          achieve desired outcomes have identified certain causes for the
          failure.  These include
 
          -- failure to use objectives to guide the program and its
             services,
 
          -- poorly designed and structured services,
 
          -- insufficient training and supervision of home visitors, and
 
          -- the inability to provide or access the range of services
             multiproblem families need because the program is not linked
             to other community services.
 
          Several examples illustrate these problem areas.#36
 
 
 
 
 
 
        36For additional evaluations of programs that were not
          successful at achieving some key objectives, but for which the
          causes of failure were not identified or discussed here, see:
          Earl Siegel and others, "Hospital and Home Support During
          Infancy:  Impact on Maternal Attachment, Child Abuse and Neglect,
          and Health Care Utilization," Pediatrics, Vol. 66, No. 2 (Aug.
          1980); Violet H. Barkauskas, "Effectiveness of Public Health
          Nurse Home Visits to Primarous Mothers and Their Infants,"
          American Journal of Public Health, Vol. 73, No. 5 (May 1983);
          Richard P. Barth and others, "Preventing Child Abuse:  An
          Experimental Evaluation of the Child Parent Enrichment Project,"
          Journal of Primary Prevention, Vol. 8, No. 4 (Summer 1988).
 
                                         42
 
 
 
 
          Child and Family Resource Program
          ---------------------------------
          The Child and Family Resource Program, a federally funded
          demonstration project initiated by the Administration for
          Children, Youth, and Families, was an ambitious home-visiting
          program that had little impact on one of its two main objectives.
          Initiated in 1973, this 11-site, home- and center-based project
          was designed to strengthen families economically and socially and
          to improve child health and development.  Paraprofessional home
          visitors helped families access needed social and health
          services, including basic education and job readiness training,
          and, through child development activities, taught parents to
          improve their parenting skills.  The program improved mothers'
          employment and educational status.  However, the program did not
          improve child health and development outcomes for the families
          randomly assigned to receive program services and only marginally
          improved parental teaching skills.
 
          Program evaluators identified three design and implementation
          weaknesses that contributed to the program's failure to improve
          child health and development.  First, home visitors did not pay
          sufficient attention to all objectives when providing services;
          they spent most of their time counseling on the need for
          continued schooling, job training, and employment, instead of
          balancing this objective with training for parents aimed at
          improving child development.  Although child development was a
          major program objective, the amount and frequency of child
          development services provided were low.  Second, the quality of
          child development activities provided may have been inadequate.
          Home visitors tended not to demonstrate activities so that
          parents could learn by imitation.  Third, program evaluators
          stated that inadequate training and supervision of home visitors
          contributed to the program's lack of success.#37
 
          Boston's Healthy Baby Program
          -----------------------------
          The HHS Inspector General reported in 1989 that Boston's Healthy
          Baby Program, an ongoing program, had similar weaknesses.  The
          program's goal is to improve birth outcomes by preventing
          premature birth through health education by home visitors.  The
          Inspector General did not address program effectiveness or
          collect complete data to determine whether program participation
          improved birth outcomes.  However, the Inspector General reported
 
 
        37Robert Halpern, "Parent Support and Education for Low-
          Income Families:  Historical and Current Perspectives," Children
          and Youth Services Review, Vol. 10, (1988); Marrit J. Nauta and
          Kathryn Hewett, "Studying Complexity:  the Case of the Child and
          Family Resource Program," in Evaluating Family Programs, Heather
          B. Weiss and Francine H. Jacobs, ed., Aldine de Gruyter, New
          York (1988).
 
                                         43
 
 
 
 
          that the program failed to accomplish four of its service
          delivery objectives.  The program was doing little outreach to
          enroll the target population, was not consistently assessing risk
          factors among program participants, was providing services late
          in pregnancy and not emphasizing all necessary health
          information, and was not well coordinated with other programs.
          Many of the program's clients contacted by the Inspector General
          who had experienced poor birth outcomes, though assessed for
          risk, had never received program services or had received them
          only postnatally.
 
          The Inspector General attributed these problems to specific
          program design and implementation weaknesses.  The program's
          objectives were not guiding the design and development of
          services.  The home visitors were poorly trained and supervised.
          In addition, the program, serving families with multiple problems
          such as inadequate housing and substance abuse, was located in an
          agency with little experience in helping such families.  The
          program staff also had not developed effective linkages with
          prenatal care providers and other social service agencies.#38
 
          Rural Alabama Pregnancy and Infant Health Program
          -------------------------------------------------
          The Rural Alabama Pregnancy and Infant Health Program, one of
          five Ford Foundation-sponsored Child Survival/Fair Start
          programs, had mixed success in meeting its objectives to improve
          birth outcomes, child health, and child development.  This
          paraprofessional home visitor program improved the use of health
          care by low-income families, including adequate immunization of
          client children.  But it did not significantly improve infant
          birthweights, infant health at birth, or infant development,
          compared to a demographically similar group of children who were
          not visited.#39
 
          Program evaluators in 1988 reported three problems with the
          program. First, compared to other Child Survival/Fair Start
          programs, the Rural Alabama Program put less emphasis on becoming
          familiar with the chosen target population of low-income young
          women and their needs.  The program was initially designed to
          have older, experienced paraprofessional women as home visitors,
          but found that younger home visitors could establish closer
          relationships and were more effective with young clients.
          Second, the program did not have a single structured curriculum
 
 
        38Office of Inspector General, Department of Health and Human
          Services, Evaluation of the Boston Healthy Baby Program  (July 1989).
 
        39J.D. Leeper and others, "The Rural Alabama Pregnancy and Infant
          Health (RAPIH) Program," presented at the 1988 Annual Meeting of
          the American Public Health Association.
 
 
                                         44
 
 
 
 
          of information to teach the clients.  Finally, program evaluators
          concluded that the home visitors needed more supervision.#40
 
          Prenatal/Early Infancy Project
          ------------------------------
          The Prenatal/Early Infancy Project in Elmira, New York,
          demonstrated impacts on birthweight, maternal health, reduction
          in child abuse, and improved maternal education or employment
          status when it was an experimental research program, but when the
          local health department took it over, the program was altered.
          As a demonstration project, the program had multiple sources of
          funding, including HHS, the Robert Wood Johnson Foundation, and
          the W. T. Grant Foundation.  When the 6-year grant funding ended
          in 1983, the local health department absorbed the program, while
          changing its definition and extent of services, target
          population, and caseload per home visitor.  As a result of these
          changes, all of the original home visitors left within a few
          months.  One director of county services told us that the program
          was no longer achieving the same reductions in low birthweight as
          the original project.
 
          The program's absence of final evaluation data in 1983, reduced
          financial support, and location within the local health
          department all contributed to the changes.  Some of these changes
          resulted from a reluctance to invest substantially in a program
          whose benefits had not yet been fully demonstrated at that time.
          But a difference in philosophy also prompted the change in
          program focus.  Local officials told us there was not unanimous
          agreement with the research program's broad health and social
          service orientation and intensity.  They also did not agree with
          limiting services to the target population of first-time mothers-
          -particularly low-income, unmarried teen mothers--even though
          these women were among the ones who benefited most from the
          experimental program.  Local officials believed that some minimum
          level of home-visiting services should be provided to a larger
          group of pregnant women, which may be diluting the overall impact
          of the formerly targeted, high-intensity services.
 
 
 
 
 
 
        40Mary Larner, "Lessons from the Child Survival/Fair Start
          Home Visiting Programs," presented at the 1988 Annual Meeting of
          the American Public Health Association; J.D. Leeper and others,
          "The Rural Alabama Pregnancy and Infant Health (RAPIH) Program,"
          presented at the 1988 Annual Meeting of the American Public
          Health Association; M.C. Nagy and J.D. Leeper, "The Impact of a
          Home Visitation Program on Infant Health and Development:  The
          Rural Alabama Pregnancy and Infant Health Program," presented at
          the 1988 Annual Meeting of the American Public Health Association.
 
                                         45
 
 
 
 
          CRITICAL COMPONENTS FOR PROGRAM DESIGN
          --------------------------------------
          Our analysis of these and other evaluations, consultation with
          experts, and interviews with federal, state, and local program
          officials point to the importance of sound program design.
          Further, evidence from these sources suggests that certain
          program design components are critical to success.  Programs
          using home visiting as an early intervention strategy can be
          successful at achieving their objectives if program designers and
          managers recognize the interplay among these critical components.
 
          Information on the success and failure of programs using home
          visiting can be found in the education, health, and social
          support literature.  Yet we could find no cross-discipline
          synthesis or analysis of the reasons for these varied outcomes.
          While no single approach exists for designing successful
          programs, we have identified critical design components with
          associated characteristics that appear to be important when
          designing and implementing programs that use home visiting as a
          service delivery strategy.  These key components include
 
          -- clear and realistic objectives with articulated program goals
             and expected outcomes,
 
          -- a well-defined target population with identified service
             needs,
 
          -- a plan of structured services designed specifically for the
             target population,
 
          -- home visitors trained and supervised with the skills best
             suited to achieve program objectives,
 
          -- sufficient linkages to other community services to complement
             the services that home visitors can provide,
 
          -- systematic evaluation to document program process and
             outcomes, and
 
          -- ongoing, long-term funding sources to provide financial
             stability.
 
          In operation, these components are not independent of one
          another.  They must work in harmony, as part of an overall
          program design framework.   The next chapter describes in more
          detail a framework that we developed to guide program design and
          management.  In addition, we illustrate, through case studies,
          how programs with varying objectives, services, and types of home
          visitors used these critical components to strengthen program
          design and operation.
 
 
 
                                         46
 
 
 
                                      CHAPTER 5
                                      ---------
                         A FRAMEWORK FOR DESIGNING PROGRAMS
                         ----------------------------------
                               THAT USE HOME VISITING
                               ----------------------
          Home visiting evaluators, experts, and managers point to certain
          common characteristics among diverse program designs as
          prerequisites to achieving program goals.  To illustrate how
          these characteristics can be used as a framework in designing and
          operating programs using home visitors, we reviewed eight
          programs operating in the United States and Europe that appeared
          to be successful in meeting their stated objectives.  (See app. I
          for more detailed information on these programs.)
 
          These eight programs commonly used home visitors to deliver
          services, yet varied in other ways.  They differed in objectives,
          in the group they targeted for services, and in the types of
          services provided.  Some operated in rural areas, others in
          urban areas.  Some used professionals, such as registered nurses
          and social workers, while others used non-college-educated
          paraprofessional community women.  (See table 5.1 for highlights
          of differences.)  Despite these differences, these programs
          illustrate the importance of certain design characteristics.  In
          general, these programs' managers
 
          -- developed clear objectives, focusing and managing their
             operations accordingly;
 
          -- planned service delivery carefully, matching the home
             visitor's skill level to the service provided;
 
          -- worked through an agency with both a health and social support
             outlook to provide families with a variety of community
             resources either directly or by referral; and
 
          -- developed strategies for ongoing funding to sustain program
             benefits over time.
 
          From these characteristics, we developed a framework for
          developing and managing programs that use home visiting.  The
          framework's constituent parts, shown in Figure 5.1, include clear
          objectives, structured service delivery procedures, integration
          into the local service provider network, and secure funding over
          time.
 
 
 
 
 
 
 
 
 
                                         47
 
 
 
 
     Table 5.1:  Characteristics of United States and European Programs GAO
                 Visited
 
     Program              Area          Population          Type of
     name                 served        served              home visitor#a
     -------              ------        -----------         ------------
     United States
     -------------
     Resource Mothers     Rural         Pregnant teens,     Paraprofessional
     for Pregnant                       teen mothers
     Teens,
     South Carolina
 
     Center for           Urban         Developmentally     Professional
     Development,                       delayed children
     Education, and
     Nutrition
     (CEDEN),
     Austin, Texas
 
     Changing the         Urban         Pregnant low-       Professional
     Configuration                      income women
     of Early
     Prenatal Care
     (EPIC),
     Providence,
     Rhode Island
 
     Southern Seven       Rural         Pregnant teens      Professional
     Health
     Department,
     Southern
     Illinois
 
     Maternal and Child   Urban         Pregnant            Paraprofessional
     Health Advocate                    women; mothers
     Program,                           with high-risk
     Detroit, Michigan                  newborns
 
     Roseland/Altgeld     Urban         Pregnant teens;     Paraprofessional
     Adolescent Parent                  teen mothers
     Project (RAPP),
     Chicago, Illinois
 
     Europe
     ------
     Great Britain        Nationwide    All newborns        Professional
     Health Visitor
 
     Denmark Infant       Nationwide    Newborns#b          Professional
     Health Visitor
 
 
                                         48
 
 
 
 
    aProfessional includes individuals with postsecondary degrees in either a
     specialized area, such as nursing, or a broader field, such as early
     childhood education or social work.  Paraprofessional includes individuals
     with no postsecondary certification or specialized training.
 
    bAll newborns in municipalities that hire home visitors (90 percent of all
     newborns).
 
 
          Figure 5.1:  Framework for Designing Home Visitor Services
 
               Clear Program Objectives
 
               Objectives, clients, and services are interdependent
               Objectives as a management tool
 
               Structured Program With Appropriate Home Visitor Skills
 
               Structured service delivery plan
               Home visitor skills matched with services
               Training and supervision tailored to home visitor needs
 
               Comprehensive Focus With Strong Community Ties
 
               Services linked with other local providers
               Agency supports multifaceted approach
 
               Secure Funding Over Time
 
               Plan for program continuity
 
          CLEAR OBJECTIVES AS A CORNERSTONE
          ---------------------------------
          Clear, precise, and realistic objectives are crucial for enabling
          programs using home visiting to sustain program focus among the
          home visitor staff and to deliver relevant services to an
          appropriate client population.  Developing such objectives forms
          the foundation for determining specific services and identifying
          the target population.  Well-articulated objectives also allow
          programs to develop outcome measures for monitoring progress.
 
          Objectives, Target Populations, and Services Are Interdependent
          ---------------------------------------------------------------
          Objectives, target populations, and services are logically
          interconnected program elements.  As program managers develop
          objectives in response to problems, such as infant mortality or
          child abuse, they also begin to identify the client needing help
          and the type of services that will suit the client.  The Center
          for Development, Education, and Nutrition (CEDEN), for example,
          developed a program using home visiting to address an expressed
          local need.  It was created in 1979 in response to a survey of
          families in East Austin, Texas, that identified delayed child
 
                                         49
 
 
 
 
          development as a pressing community problem.  To address
          children's developmental delays, program managers selected as a
          target population children most likely to benefit from program
          services--those under age 5, with an emphasis on those under age
          2.  This selection was based not only on the expressed need of
          the community, but also on an assessment of those most likely to
          benefit from the proposed services--in this case, very young
          children, who are more responsive than older children to measures
          for preventing and reducing developmental delay.
 
          Program managers must be realistic in developing objectives and
          services.  In some instances it may not be possible--or
          practical--to meet the needs of all the program's target
          population, especially those at highest risk.  Roseland/Altgeld
          Adolescent Parent Project (RAPP) in Chicago helps pregnant and
          parenting teens with parenting skills and self-sufficiency.  The
          program does not accept certain members of its target group who
          have severe problems, such as mental or emotional disorders or
          substance abuse.  Program officials do not think these women
          would benefit from the program because the program services are
          not intense enough to help them.  RAPP refers women with these
          problems to other programs.  The program also does not serve
          teens who have strong family support and who function well
          independently.
 
          In programs that use home visiting, objectives serve as the basis
          for determining the frequency of visits and duration of services.
          CEDEN, for example, has determined that most children will have
          achieved normal or better levels of development after 24 to 34
          weekly home visits, so that is the expected length of program
          services.  The number of visits per child and specific goals and
          activities vary, however, according to the child's individual
          needs.
 
          Objectives as a Management Tool
          -------------------------------
          Clear objectives also serve as the basis for determining outcome
          measures used in program monitoring and evaluation.  For example,
          if a program's objective is to reduce the incidence of child
          abuse among violence-prone families by teaching appropriate
          discipline methods, then comparing the number of reported abuse
          incidents among families receiving program services to incidents
          among similar families not receiving program services is one
          logical measure.
 
          Managers use outcome measures derived from program objectives to
          monitor program performance and to make changes.  CEDEN examines
          information collected from children at entry, mid-program, and
          exit on perceptual abilities, fine and gross motor skills,
          language skills, and cognitive development to measure progress
          toward its objectives of preventing or reversing developmental
          delay.  It also compares entry and exit statistics for well-child
 
                                         50
 
 
 
 
          checkups, immunizations, illness and hospitalization rates, and
          the number of children with medical coverage to measure progress
          toward objectives related to improving the health of program
          children.
 
          RAPP also measures progress quarterly by determining whether its
          clients receive certain services.  For example, to monitor its
          objective of increasing well-baby care, RAPP measures the number
          of infants getting regular health screening.  During the 1989
          fiscal year, the program had already exceeded its annual goal of
          175 total screenings for all clients by the end of the third
          quarter.
 
          Periodic monitoring serves at least two purposes.  First and
          foremost, it demonstrates whether a program has met its goals.
          Second, program objectives, target population, and services can
          be modified if needed.  The monitoring experiences of CEDEN and
          South Carolina Resource Mothers serve to illustrate how
          monitoring provides important information to managers.
 
          At the time of our review, preliminary results from an external
          evaluation of CEDEN showed that the program was effective in
          reducing developmental delays in client children.  Further,
          CEDEN's executive director said that preliminary results suggest
          that the program should
 
          -- emphasize referring both children and mothers to appropriate
             health and human service programs,
 
          -- focus on efforts to follow up on families in order to
             complete more home visits, and
 
          -- begin to follow up on families no longer in the program to
             determine if gains in development are sustained.
 
          South Carolina's Resource Mothers program has been involved in a
          number of evaluations. These show that the program has been more
          successful at meeting some objectives than others.  A 1986
          evaluation showed that teens visited by Resource Mothers had
          fewer low-birthweight babies than teens in nearby counties who
          did not have access to the program.  However, a 1989 evaluation
          showed that the program has not been as successful in such areas
          as encouraging mothers to breast-feed their babies, enroll early
          in family planning, and immunize their children at the
          appropriate times. The state coordinator said that program
          managers will use the evaluation results to determine if any of
          the objectives should be changed.
 
          Each of the six U.S. case studies we reviewed had evaluation
          components, although they differed in the level of
          sophistication.  None, however, had completed evaluations that
          compared costs to relative benefits.  Therefore, program managers
 
                                         51
 
 
 
 
          could not clearly document the cost savings that each believed
          they were achieving.
 
          STRUCTURED PROGRAM DELIVERED BY SKILLED HOME VISITORS
          -----------------------------------------------------
          A "structured" service delivery approach--one that has defined
          activities and a sequenced plan for instruction with a detailed
          curriculum or protocol--serves as a blueprint for guiding home
          visitor services.  The degree of service structure, such as using
          written curricula or making a specified number of visits, can
          depend upon program objectives and whether professional or
          paraprofessional home visitors are used.  Programs with multiple
          and complex objectives, such as reducing children's developmental
          delays, benefit from a plan that details service activities.
          Programs delivered by paraprofessional home visitors also
          benefit from more planned service activities.
 
          The skills of the provider need to match the services provided.
          Programs that deliver technical services, such as medical and
          psychological examinations, require highly trained, professional
          home visitors.  On the other hand, programs that deliver
          information and provide referrals to other service agencies do
          not need as highly trained home visitors.
 
          Structured Service Delivery
          ---------------------------
          Structuring services with a written curriculum can be
          particularly advantageous for programs using home visitors.
          Reviews of multiple early intervention program evaluations have
          shown that programs using structured interventions and written
          curricula were more likely to improve children's development.
          Officials of programs we visited said that structured service
          delivery
 
          -- promotes the guidance of services by objectives,
 
          -- fosters consistency and accuracy of information provided to
             clients, and
 
          -- enables home visitors and their supervisors to systematically
             plan future services for clients.
 
          Despite this evidence, one survey of home-visiting programs
          indicated that only a third used written curricula.
          Four of the six U.S. programs we reviewed used structured
          curricula--each one developing its own.  The Resource Mothers
          program, which uses paraprofessionals, is highly structured.  The
          program has a detailed set of protocols that describes the
          information to be covered during each visit.  Generally, each
          client receives the same services on the same schedule--tied to
          month of pregnancy and age of the baby.  The home visitor can
 
 
                                         52
 
 
 
 
          deviate from this plan, however, to deal with a client's
          particular needs.
 
          The Illinois Southern Seven program, which uses professionals, is
          less structured.  It provides numerous services--referrals,
          emotional support, education on prenatal care and parenting
          skills, and well-baby assessments--without structured protocols
          to follow during visits.  Southern Seven also does not prescribe
          the frequency or minimum number of home visits necessary to meet
          program objectives.  Home visitors decide how many visits are
          needed based on a risk assessment done for each client.
 
          Despite variations in the level of service delivery structure,
          home visitors, their supervisors, and program managers agreed on
          the need to be flexible during the home visit.  Responding to a
          family's most immediate concerns is important for building a
          helping relationship.  During one GAO site visit, for example, a
          home visitor had planned to work with a child for 1 hour but
          instead spent 4 hours helping a family member receive emergency
          medical care.
 
          Match Between Program Services and Home Visitor Skills
          ------------------------------------------------------
          The experience of home-visiting experts reinforces what appears
          to be intuitively true:  programs delivering specialized,
          technical services need to use educated and skilled home
          visitors.  British health visitors, for example, provide hands-on
          medical services in the home, such as head-to-toe examinations
          of newborns 10 to 14 days old.  Because Denmark's and Great
          Britain's health-visiting services focus on both preventive
          health and secondarily deal with mental, social, and
          environmental factors that influence family behavior, these
          nurses have medical, social service, and counseling backgrounds.
 
          Austin's CEDEN services are tailored by the home visitors for
          each child's diagnosed developmental delay.  Home visitors
          develop their individualized services by picking from a number
          of different activities.  The staff are college graduates trained
          in a variety of disciplines, including social work, psychology,
          and nursing.  The executive director affirmed that the home
          visitors' independent planning and assessments required this
          level of education.
 
          Many services, while not requiring highly skilled professionals
          for their effective delivery, do require trained
          paraprofessionals.  Detroit's Health Advocate home visitors, for
          example, teach pregnant clients about proper eating habits,
          infant care, problem solving, and birth control.  They assist
          new clients to meet their basic needs first, since some clients
          lack food, clothing, income, or shelter.
 
 
 
                                         53
 
 
          Training and Supervision Tailored to Home Visitor Skills
          --------------------------------------------------------
          Programs we visited using paraprofessional home visitors
          generally provided more training--both before (preservice) and
          after (in-service) home visiting began--than did programs using
          professionals.  Detroit's Health Advocate program provided a
          full-time, preservice, 6-week training course, including such
          topics as human development and use of community resources.
          Chicago's RAPP provided preservice training entailing a week of
          program orientation and a month of supervised, on-the-job
          training.
 
          Both programs also provided in-service training.  The Health
          Advocate's training coordinator regularly discussed in-service
          training needs with home visitors and their supervisors.  RAPP
          paid for external training and encouraged its home visitors
          without college degrees to pursue further education.
 
          Programs we visited using highly trained, professional home
          visitors tended to provide less direct training.  For example,
          the Changing the Configuration of Early Prenatal Care (EPIC)
          project in Providence, Rhode Island, used nurses from the
          Visiting Nurse Association, Inc., with bachelor of science
          nursing degrees.  Because each nurse home visitor had medical
          training, knowledge of community resources, and at least 8 years
          of home-visiting experience, the project director did not view
          extensive training as a critical program component.  Nurses were
          oriented to the program but not otherwise trained.
 
          British health visitors require little additional training
          because they are extensively trained and credentialed before they
          can join a district health authority.  Experienced registered
          nurses with community nursing experience receive an additional 51
          weeks of home visitor classroom and supervised field training.
          They are credentialed through a national system before joining
          the ranks of the District Health Authority's home health
          visitors.
 
          Program officials, managers, and home visitors we contacted--
          regardless of program objectives--often talked about the need to
          be adequately trained and prepared in a variety of areas in order
          to be responsive to their clients' multiple needs.  Some spoke
          specifically about advantages associated with cross-training--
          formal joint training for home visitors of various disciplines---
          and the development of a core training curriculum that would be
          appropriate for all home visitors. The British health visitor and
          home-based Head Start training materials are examples of core
          curricula that other programs using home visitors might adopt.
 
          A common personnel component among all home visitor programs was
          a stated need for supervision and support.  Program officials saw
          home visiting as a stressful occupation.  Both home visitors and
          their supervisors believed that supervisors play a critical role
 
                                         54
 
 
 
 
          in relieving stress and providing advice on how to work with
          clients and handle caseloads.  Most of the officials of programs
          we visited in the United States that use both professional and
          paraprofessional staff agreed that the latter require closer
          supervision.  The Detroit Health Advocate program experienced
          early difficulty with its choice of home visitors--former AFDC
          mothers.  Program managers and supervisors found that these home
          visitors experienced difficulties adjusting to their new
          responsibilities and required more support and supervision than
          initially anticipated.
 
          Detroit's Health Advocate supervisors accompanied their
          paraprofessional home visitors at least once a month, reviewing
          each case with the visitor before the next visit.  In contrast,
          British home visitors are expected to work independently with
          little day-to-day supervision.  British supervisors have multiple
          duties, such as hiring new staff and allocating nursing
          resources, and therefore spend limited time on reviewing
          individual cases.  In Denmark, local health authorities are not
          required to hire supervisors for home visitors; in 1986, 69
          percent of 277 municipalities had not hired supervisors.
 
          STRONG COMMUNITY TIES IN A SUPPORTIVE AGENCY
          --------------------------------------------
          Home visitors can help clients overcome some access-to-service
          problems by coordinating or providing needed services.  In their
          coordination role, home visitors act as case managers for their
          clients, by locating and helping their clients obtain varied
          services from different sources.  To do so, home visitors develop
          techniques to link clients with various community programs and
          service providers.  Programs using home visiting benefit from
          being located in agencies supportive of and experienced with
          providing combined health, social, and educational services to
          families.
 
          The success of home visitors in coordinating services for clients
          depends largely on the availability and quality of community
          resources.  In areas where services are limited, home visitors
          can help women get access to what care is available. However,
          home visiting does not substitute for other needed services, such
          as prenatal care.
 
          Linkages With Other Programs
          ----------------------------
          Home visitors need to be familiar with the community's health,
          education, and social services network and must develop
          relationships with individual providers in order to link clients
          with needed community services.  Sometimes home visitors
          accompany clients to an agency office to help them make initial
          contacts with agency staff.  They also provide clients with
          reference materials listing community resources.
 
 
                                         55
 
 
 
 
          Detroit's Health Advocate program developed links to community
          resources by participating in provider networks.  The program's
          managers belonged to a number of local service networks, such as
          Michigan Healthy Mothers, Healthy Babies and Detroit/Wayne County
          Infant Health Promotion Coalition.  The goal of these
          organizations was to promote better overall community access to
          prenatal care.  Health Advocate managers helped organize local
          prenatal clinics into a network that met regularly to find ways
          to improve access to care.
 
          The CEDEN program also relied on other agencies and
          organizations for services to complement its own.  CEDEN
          maintained a computer-based system of about 200 agencies
          offering such services.  CEDEN's home visitors learned local
          agency procedures so they could help clients complete forms
          correctly.  Home visitors had specific contacts within the
          agencies administering WIC and Medicaid, for example, whom they
          could call on to link clients with services.  Like the Health
          Advocate program managers, CEDEN officials were members of
          various committees and councils that addressed the educational,
          social services, and medical needs of Travis County (Austin)
          residents.  These included the Early Childhood Intervention Forum
          and the Austin Area Human Services Network.
 
          U.S. program managers we visited that used home visiting said
          that it was important to link their programs with other service
          providers in the community.  Often programs are not designed to
          provide comprehensive services, and clients may not know where to
          go for help or may need encouragement to go.  U.S. program
          managers believed this linkage was a critical part of their
          programs' success.
 
          In contrast, British and Danish health officials did not believe
          that the success of their health-visiting programs is as
          dependent on the strength of the local service community.  In
          Great Britain and Denmark, health visitors work as a part of a
          community-based primary health care team consisting of a general
          practitioner, a midwife, and a home visitor.  As a result, they
          do not depend on referrals to coordinate medical care as U.S.
          programs do.  For other services, however, health visitors
          maintain a close working relationship with certain community
          support agencies.  When British health visitors are confronted
          with particular problems, such as child abuse, they report the
          family to social services.  The family's home visitor meets
          monthly with police and social services to coordinate home-
          visiting services with social and protective services for the
          child.
 
          Location Within Supportive Agency
          ---------------------------------
          Programs that used home visiting often had mixed social, health,
          and child development objectives.  These programs are enhanced
 
                                         56
 
 
 
 
          when housed in agencies supportive of the delivery of
          multifaceted services.  We visited programs with different types
          of agency affiliation--administered by a social service agency
          within a health department, a university, or an agency
          experienced in delivering family services addressing various
          problems.  All of these agencies were supportive of the programs'
          multiple objectives and family-centered approach.
 
          The local health department's division of social services
          operates the Southern Seven program.  This organizational
          arrangement seems to enhance the home-visiting program's ability
          to meet both its social support and health-related objectives.
          In addition, clients have greater access to the department's
          other services, such as prenatal care.
 
          In the Resource Mothers program, each supervisor has a master's
          degree in social work and is primarily responsible to the local
          health department's social work director.  The health department
          provides such services needed by Resource Mothers clients as
          prenatal care and family planning services. In some locations,
          the South Carolina Department of Social Services has an employee
          located in the local health department so people can apply for
          Medicaid without going to the local Department of Social Services
          office.
 
          Catholic Charities' Arts of Living Institute is the parent
          organization for RAPP.  This private, nonprofit organization
          develops and operates programs for pregnant teenagers and
          coordinates with other agencies to deliver services that they
          cannot directly provide.  Since Catholic Charities has expertise
          in delivering services related to RAPP's goals, it can advise and
          assist RAPP on how to best achieve program goals.
 
          Home Visiting Does Not Substitute For Lack of Services
          ------------------------------------------------------
          Regardless of how well services are coordinated, programs
          providing supportive services through home visiting do not
          substitute for some gaps in community services.  A clear example
          is prenatal care.  Women who obtain inadequate prenatal care are
          less likely to have a healthy birth outcome than women who obtain
          adequate care.  While the Institute of Medicine recommends that
          programs providing prenatal care to high-risk women include home
          visiting, it recommends that the first task for policymakers is
          making prenatal care more accessible to all.
 
          Programs that use home visiting can help women access what care
          is available.  Southern Seven officials said prenatal care and
          hospital delivery services are inadequate in their rural Illinois
          area.  No hospital in the 2,000-square-mile area served by the
          program provides delivery room services.  Only four local doctors
          provide prenatal care, and two of them do not participate in
          Medicaid.  Program officials transport their clients to doctors
 
                                         57
 
 
 
 
          inside and outside the seven counties to help them obtain needed
          care.  The nearest hospitals with delivery facilities are in
          Missouri and Kentucky, but these states do not accept Illinois
          Medicaid.  Medicaid beneficiaries therefore have to drive 40 to
          60 miles to Carbondale to deliver their babies.  Although, for
          legal reasons, Southern Seven home visitors are not allowed to
          transport women in labor, they make sure such women have
          transportation to the hospital by ambulance if no other means
          are available.
 
          Southern Seven was the only program we visited that cited such a
          serious gap in medical services.  The other programs cited other
          service gaps, such as inadequate public transportation, mental
          health and drug rehabilitation services, child care, and
          affordable housing.
 
          ONGOING FUNDING FOR PROGRAM PERMANENCY
          --------------------------------------
          Developing strategies to secure ongoing funding strengthens
          home-visiting services by giving programs time to establish
          themselves in the community, build and maintain relationships
          with clients and other providers, and maintain steady program
          operations.  Since it takes time to demonstrate a program's
          effect, secure funding gives it an opportunity to do so.  But
          three of the six U.S. programs we visited were developed as
          time-limited projects,#41 without guaranteed sources of
          continuing funding.  Two of these ceased operation by the end of
          1989.  The other four programs, however, successfully developed
          strategies to maintain services in an uncertain funding
          environment.
 
          Time Needed to Implement and Demonstrate Effectiveness
          ------------------------------------------------------
          Developing, implementing, and evaluating the impact of home-
          visiting services while maintaining continuity of services takes
          several years.  Three-year or shorter funding cycles put
          considerable pressure on programs to achieve complete
          operational status and show some positive effects before ending.
          Based on the experience of many programs using home visiting,
          experts have concluded that funding insecurity is one of the
          basic sources of unpredictability and unevenness in delivering
          home-visiting services.
 
          Uncertain funding contributes to operational problems in home-
          visiting services.  It can result in high turnover which, in
          turn, is disruptive to service, increases the need for training,
          and contributes to program instability.  The Health Advocate
          program, for example, had a serious turnover problem, partially
          due to its initial way of paying home visitors.
 
 
        41EPIC, Resource Mothers, Health Advocates.
 
                                         58
 
 
 
 
 
          At the beginning, the program's home visitors, who were AFDC
          recipients, were given supplementary Volunteers in Service to
          America (VISTA)#42 payments instead of becoming regular salaried
          employees.  When other local health departments established
          programs similar to Health Advocates using paraprofessionals,
          Health Advocate home visitors moved to these more secure jobs.
          None of the 21 original home visitors who started in early 1987
          were still visiting clients in August 1989.  Consequently, the
          program lost clients because some, having established a rapport
          with the first home visitor, did not want to continue the
          program once "their" home visitor left.  The Health Advocate
          program had to train additional home visitors to keep an ongoing
          staff.
 
          Some U.S. programs we visited needed funding for longer than 3
          years if they were to continue services and demonstrate their
          effectiveness.  Although the first formal Resource Mothers
          program evaluation demonstrated that clients had better birth
          outcomes, for example, it was not completed until more than 5
          years after the initial research program began.  By that time,
          the original 5-year foundation grant had expired, and the
          program was operating through a 3-year federal Special Projects
          of Regional and National Significance (SPRANS)#43 grant.  Had the
          Resource Mothers program not received a second grant, the results
          of the original evaluation could not have been used to help
          secure further funding.
 
          Providence's EPIC program also received a 3-year federal SPRANS
          grant, from October 1986 to September 1989. During those 3 years,
          program officials developed, implemented, and completed the
          program.  They also began but did not complete its evaluation.
          They stopped providing program services in June 1989. The
          program was planned as a research project to see if nurse home
          visiting between weeks 20 and 30 of pregnancy could improve birth
          outcomes.  Although no immediate state commitment to such funding
          was sought, health officials may seek longer term funding to
          restart the program if it proves to have been effective.  Final
          evaluation results were expected by spring of 1990, about 1 year
          after program services were terminated.
 
          The Health Advocate program was also a 3-year project that closed
          its doors in October 1989 with its evaluation to be completed
          later.  Program officials were awaiting evaluation results to
 
 
        42VISTA provides small stipends to full-time volunteers who
          work for governmental or nonprofit agencies on projects to
          improve the lives of the poor.
 
        43These projects are funded by a federal set-aside of between
          10 and 15 percent of the MCH block grant appropriation.
 
                                         59
 
 
 
 
          determine the impact of the home visits on their clients.  In the
          meantime, the program has been partially replicated by some
          local health departments that saw its benefits and merits, and
          program staff have begun a new, community-based maternal and
          child health home-visiting effort.
 
          CEDEN, a private, nonprofit organization, has had more stable
          funding over its 10-year existence than some of the other
          programs.  According to the executive director, this has allowed
          the program to establish ongoing relationships within the
          community, with other service providers, and with clients.  CEDEN
          is well known and well respected by members of the community and
          other area service providers.  As a result, many CEDEN clients
          are referred from diverse sources--other social service
          providers, medical providers, police, family violence programs,
          churches, other institutions, and previous clients.
 
          Historically, Great Britain has not had the kind of funding
          uncertainty as have some U.S. programs.  Since home visiting is
          one component of community health services provided by the
          National Health Service, it is a firmly established part of the
          local community.  Home visiting has a long tradition in Great
          Britain and is a respected profession.  As a result, home
          visitors serve as a common point of reference in the community,
          sources of standard information, advisors on health, and
          overseers of child welfare.
 
          Funding Strategies Needed to Maintain Services
          ----------------------------------------------
          The U.S. programs we visited that were able to maintain
          continuous funding of program services followed two strategies.
          These entailed developing diverse funding sources, either by
          themselves or through sponsoring organizations, and designing
          programs to be more closely integrated into the community.
          Programs that did not maintain services after initial funding
          ended generally depended solely on 3-year research demonstration
          grants.
 
          Developing diverse funding sources was one strategy for coping
          with funding uncertainty.  Home visitor programs have the
          potential to tap diverse funding sources because the potential
          funding for early intervention is so diversified.  CEDEN, a
          community-based agency, has obtained, in addition to federal,
          state, and local funds, funding from private foundations like
          the Ford Foundation and The March of Dimes Birth Defects
          Foundation, nongovernmental grants from the United Way and Junior
          League, and corporate contributions from IBM and Motorola.
          According to CEDEN's executive director, a diverse funding base
          prevents the loss of one funding source from disrupting the
          program.
 
 
 
                                         60
 
 
 
 
          RAPP and Southern Seven also benefit from diverse funding
          sources developed by The Ounce of Prevention Fund, itself a major
          funding source.  The Ounce of Prevention Fund is a public-private
          consortium, with funding from various governmental sources,
          foundations, and private sector contributions.  Because of such
          diverse funding sources, RAPP and Southern Seven program
          administrators are freed from having to search independently for
          funding.  As a result, they can devote their efforts to program
          management.
 
          Designing programs to be integrated into the community, thereby
          building local support and commitment for the program, is another
          strategy that can lead to more stable funding.  The Resource
          Mothers Program was introduced into rural communities through
          town meetings.  Community groups involved themselves in finding
          and funding local operation sites.  The program became an
          established part of local community services and was able to
          successfully replace demonstration project funding with more
          ongoing state-administered funds, such as the MCH block grant
          and other state funds.
 
 
 
 
                                         61
 
 
 
                                      CHAPTER 6
                                      ---------
                            CONCLUSIONS, RECOMMENDATIONS,
                            -----------------------------
                                 AND AGENCY COMMENTS
                                 -------------------
          CONCLUSIONS
          -----------
          Home visiting is a technique widely used in both the United
          States and Europe to provide families with preventive, in-home
          services.  Home visitors provide a broad range of services,
          including home-based assessments, education, emotional support,
          referrals to other services, and, in some cases, direct care.
 
          In Great Britain and Denmark, home visiting is part of a
          universally available system of health care.  Great Britain's and
          Denmark's publicly financed, community-based health care systems
          offer home-visiting services, without charge, to virtually all
          families with young children.  In these countries, public health
          nurses provide primarily health education and emotional support,
          with some developmental assessments and direct care, such as
          newborn health checkups.
 
          Home visiting is different in the United States.  In contrast to
          the European countries we visited, no single federal home-
          visiting program or federal focal point for home visiting exists;
          rather, the federal government funds home visiting through many
          agencies and programs.  In the United States, home visiting may
          be conducted by professional nurses, social workers, child
          development specialists, or paraprofessionals (lay workers).
          Home visiting in the United States usually targets families with
          specific problems, such as families with handicapped children or
          abusive families.
 
          Despite the variations in philosophy and approach, the goals of
          home visiting in both the United States and in Europe are
          similar: improved child health, welfare, and development.  We
          believe that home visiting can help families become healthier,
          more productive, and self-sufficient, given certain conditions.
          Our conclusions about home visiting services in the United States
          follow.
 
          -- Home visiting can be an effective strategy for reaching at-
             risk families typically targeted by early intervention
             programs.
 
          Evaluations of programs that used home visiting have demonstrated
          that this strategy can improve the health and well-being of
          families and children who often face barriers to care.  Clients
          of some home-visiting programs have had healthier babies.  Home-
          visited children have improved in intellectual development.
          Projects working with parents likely to abuse or neglect their
          children have been able to reduce reported abuse and neglect.
 
                                         62
 
 
 
 
 
          Given limited public resources, we believe that home visiting
          should be targeted to specific populations most likely to benefit
          from these personalized services.  These might include young,
          poor mothers, particularly single mothers; they have clearly
          benefited from past programs.  Children who are handicapped,
          developmentally delayed, at risk of abuse and neglect or poor
          health and development, or live in rural areas also have been
          shown to benefit from home-visiting services.  One way to target
          without stigmatizing the service is to make home visiting
          universally available in neighborhoods with high concentrations
          of at-risk families.
 
          The public costs associated with problems faced by these
          vulnerable children and families are high.  While cost data are
          limited, evaluations have shown that home visiting can reduce
          other costs.  But little is known about the cost-effectiveness of
          home visiting, compared to other settings or strategies for
          providing similar services.
 
          Despite home visiting's potential effectiveness, it is not a
          panacea for the problems disadvantaged families face.  Home
          visiting can help families overcome some of the barriers to care
          that they face, such as not understanding the need for preventive
          services or not being able to gain access to services on their
          own.  But home visiting cannot make up for lack of available
          community services, such as prenatal care providers, hospital
          delivery services, substance abuse treatment services, Head Start
          services, or affordable housing.  For communities with troubled
          populations and limited services, home visiting alone may not be
          the appropriate intervention strategy.
 
          -- Successful programs using home visiting share common
             characteristics that strengthen program design and
             implementation.
 
          The benefits of home visiting depend on certain program design
          characteristics.  Health, educational, and family support
          programs that use home visiting need clear and realistic
          objectives.  Precise objectives help sustain program focus and
          form the basis for determining the most appropriate services for
          the needs of a target population, as well as program outcome
          measures.  Home-delivered services should have well-articulated
          and defined activities with a sequenced plan for presentation to
          the client.  Programs delivering specialized and technical
          services in the home, such as well-baby health checkups or
          specialized child development services, need more structure and
          more educated, skilled visitors than programs delivering
          information, support, and referrals to other providers.  Home
          visitors need solid pre- and in-service training and close
          supervision from professionals.  This program support is
 
 
                                         63
 
 
 
 
          particularly important for paraprofessionals, but professionals
          also benefit from supportive supervision and training.
 
          We believe that no single "best" home-visiting model or approach
          exists.  Home visiting can take a variety of forms--varying in
          terms of who provides the services (professional or
          paraprofessional), what services they provide (hands-on services
          or referrals to other providers), and how frequently services are
          provided (single assessment visits or sustained visiting over 1
          or more years)--depending on the objectives, target population,
          and expected outcomes.  The critical point is to match objectives
          and services to the target population's needs and to the home
          visitors' skills and abilities.
 
          To have sustained impact, programs using home visiting need to
          develop strategies for securing ongoing funding and become
          permanent institutions within the community.  Ongoing funding
          sources provide financial stability and increase a program's
          longevity, community acceptance, and client participation.
          Medicaid is one such source of ongoing funding.  State funding,
          such as support for handicapped education, is another.  To become
          a more permanent part of the local service structure, programs
          using home visiting need to be located within agencies or
          departments that can be supportive of interdisciplinary programs
          that offer both health and social services and are willing to
          make a commitment to ongoing service delivery.  Programs using
          home visiting need to link closely with other community services,
          to help home visitors be effective case managers.
 
          -- The federal government's commitment to home visiting can be
             better coordinated and focused.
 
          Both the Congress and executive agencies appear to agree that
          home visiting can be a viable service delivery strategy, and have
          provided funding through numerous agencies and programs.  The
          federal government, however, needs to better focus and coordinate
          its efforts to improve program design and operation.  The
          government should also play a greater role in communicating
          program successes and lessons learned from perceived failures, to
          adequately design, implement, and evaluate programs.  We believe
          this can be done through existing resources and mechanisms.
 
          The Congress has indicated its interest in home visiting in
          recent legislation.  The Omnibus Budget Reconciliation Act of
          1989 authorized a new federal set-aside from the MCH block grant
          for maternal and infant home-visiting demonstration programs,
          among other projects.  Funds will become available when the block
          grant appropriation exceeds $600 million (currently at $561
          million).  Twenty-four states have used the Congress' recent
          Medicaid expansions to offer home visiting as part of Medicaid-
          covered enhanced prenatal and/or postnatal care services.  Home
          visiting is not, however, a specific Medicaid-covered service.
 
                                         64
 
 
 
 
          The Congress considered making home visiting an explicitly
          covered service for high-risk pregnant women and infants in the
          last session, but the proposal did not survive reconciliation.
          The Congressional Budget Office has estimated that the additional
          federal costs of amending the Medicaid statute to explicitly
          cover home visiting for high risk pregnant women and infants when
          prescribed by a physician would range from $95 million for fiscal
          years 1990-94 if home visiting was an optional service to $625
          million if mandatory.
 
          HHS and the Department of Education have mechanisms for
          collaborating with states and localities and helping them develop
          programs for providing early intervention services to children.
          The Federal Interagency Coordinating Council is one mechanism for
          sharing information at the federal level on successful service
          approaches and for cooperating on joint projects.  It has already
          been involved in one national conference on home visiting.  With
          its emphasis on interagency and intergovernmental collaboration
          for family support programs, FICC appears to be a ready focal
          point for further home-visiting initiatives, especially
          information exchange.  Other federal mechanisms that can support
          home visiting include existing clearinghouses and technical
          assistance to states, localities, and providers to help them
          initiate home-visiting services or to improve current services.
 
          One area that needs focus is training and service curricula.
          Programs that we visited often developed their own curricula.
          Programs could benefit from existing materials, such as The Head
          Start Home Visitor Handbook.  Federal agencies that fund home
          visitors could pool resources to develop comprehensive training
          curricula, training materials, and visiting protocols that local
          programs could use or adapt.  Well-developed training and
          visiting protocols would both improve home-visiting practices and
          decrease the start-up time and costs for new programs.
 
          Federal demonstration projects could be better focused to improve
          program practice and fill information voids.  This might include
          stepped-up federal efforts to encourage the integration of home
          visiting into existing community service networks where
          particular program approaches have proven to be effective or to
          require grantees to develop concurrent or subsequent funding
          streams in order to continue services after the demonstration
          period.  Federal demonstrations need to focus on evaluating the
          costs and future cost savings associated with home visiting, not
          just the efficacy of alternate service delivery strategies.
          Finally, federal program managers need to encourage the
          replication of proven, effective program designs in other
          communities.
 
 
 
 
 
                                         65
 
 
          MATTER FOR CONGRESSIONAL CONSIDERATION
          --------------------------------------
          The Congress has expressed its interest in home visiting as a
          strategy for bolstering at-risk families.  In view of the
          demonstrated benefits and cost savings associated with home
          visiting, the Congress should consider establishing a new
          optional Medicaid benefit: as prescribed by a physician or other
          Medicaid-qualified provider, prenatal and postpartum home-
          visiting services for high-risk women, and home-visiting services
          for high-risk infants at least up to age 1.  Making home
          visiting an explicitly covered Medicaid service to improve birth
          outcomes will encourage states to provide ongoing funding for
          prenatal and postpartum home visiting.
 
          RECOMMENDATIONS
          ---------------
          We recommend that the Secretaries of HHS and Education require
          federally funded programs that use home visiting to incorporate
          the following program design elements:
 
          -- clear objectives, which are used to manage program progress
             and to evaluate program outcomes;
 
          -- structured services by trained and supervised home visitors
             whose skills match the services they deliver;
 
          -- close linkages to other service organizations to facilitate
             access to needed services; and
 
          -- commitments for further funding beyond any federal
             demonstration period to sustain benefits beyond short-term
             initiatives.
 
          More specifically, the Secretary of HHS should incorporate these
          program design components when implementing provisions of the
          Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239)
          pertaining to new home-visiting demonstration projects.
 
          We further recommend that the Secretaries of HHS and Education:
 
          -- make materials on home visiting more widely available through
             established clearinghouses, conferences, and communications
             with states and grantees.
 
          -- provide technical or other assistance to programs to more
             systematically evaluate the costs, benefits, and future cost
             savings associated with home-visiting services.
 
          -- give priority to collaborative, interagency demonstration
             projects designed to (1) meet the multiple needs of target
             populations, (2) incorporate home visiting permanently into
             local maternal and child health and welfare service systems,
             and (3) replicate models that have demonstrated their
             efficacy.
 
                                         66
 
 
 
 
 
          -- charge the Federal Interagency Coordinating Council with the
             federal leadership role in coordinating and assisting home-
             visiting initiatives through such activities as (1) providing
             technical assistance in developing program services and
             program evaluations and (2) supporting the development of a
             core curriculum for home-visitor training.
 
          AGENCY COMMENTS
          ---------------
          HHS and the Department of Education generally concurred with our
          conclusions and recommendations.  They supported our
          characterization of home visiting as a strategy to provide early
          intervention services to certain targeted populations, and not a
          stand-alone program.  The departments agreed with the need to
          more systematically evaluate programs incorporating home-visiting
          services and provided examples of cost evaluation studies in
          process.  These cost studies may help fill some of the current
          knowledge voids, provided their results are well publicized and
          easily accessible.  They also indicated they will attempt to make
          home-visiting materials more widely available through existing
          mechanisms, such as established clearinghouses.
 
          Both departments recognized the merit of the design elements that
          we recommended be incorporated into programs that use home
          visiting.  HHS stated it will apply them to home-visiting
          services provided through the MCH block grant and will consider
          their applicability to other departmental programs.  Although
          Education provided examples where some of the design elements are
          already incorporated as program funding criteria, the department
          believes that more systematic research is needed to identify
          which variables are causally related to specific outcomes and
          suggested that the efficacy of these components be verified
          through research rather than requiring that they be included in
          every program funded.
 
          We believe that these program design elements--developed through
          an extensive literature review, consultation with experts, and
          case study analyses--reflect sound management principles that
          should be considered when designing and managing programs that
          incorporate home visiting.  For this reason, we do not believe
          additional research is needed to demonstrate the causal link
          between these general design elements and overall program
          success.  But we agree that identifying the relative
          effectiveness of variations within these design elements--such as
          the optimal type of home visitor considering stated goals and
          target populations or the nature and intensity of services--may
          warrant further research and evaluation.
 
          Both HHS and Education agreed with our recommendation to give
          priority to federal demonstration projects that meet the multiple
          needs of target populations and replicate models of proven
 
                                         67
 
 
 
 
          efficacy.  But both were hesitant to give priority to home
          visiting over other early intervention approaches or settings, in
          the absence of conclusive evidence of its relative effectiveness.
          We agree that priority should not necessarily be given to home
          visiting over other effective approaches.  Our intent was to
          emphasize the importance of integrating effective services into
          existing local-level service delivery systems on a continuing and
          sustained basis, rather than continuing to fund short-term,
          finite, experimental research and demonstration projects with
          little lasting community value.
 
          HHS did not fully concur that FICC should have the federal
          leadership role in coordinating and assisting home-visiting
          initiatives, believing this to be somewhat beyond FICC's stated
          mission of serving handicapped children.  As discussed on earlier
          pages, FICC has already conducted high-profile activities related
          to home visiting and appears to be an established interagency
          mechanism that could facilitate the federal government's
          involvement with home-visiting activities.  This role appears to
          fit within FICC's stated goal of developing action steps that
          promote a coordinated, interagency approach to sharing
          information and resources, especially materials, resources,
          training, and technical assistance to agencies and states serving
          children eligible for services under Public Law 99-457.
 
          HHS did not agree that amending the Medicaid statute to cover
          home visiting as an optional service was necessary.  It pointed
          out, as did we, that states essentially have that option, since
          some types of home visiting are presently covered under different
          categories of service.  But we believe that explicitly making
          home visiting an optional covered service would send a clear
          message to the states about the efficacy of home visiting as a
          preventive service delivery strategy and would encourage its use,
          particularly for high-risk pregnant women and infants.
 
          Finally, HHS commented on the scope of our review.  HHS believed
          we did not adequately address the different contexts in which
          U.S. and European programs using home visiting operate.  In
          chapters 2 and 6, we characterized these different operating
          environments, especially noting Great Britain's and Denmark's
          systems of universal, publicly financed, community-based
          services, available to all regardless of family income.  But
          rather than focusing on such contextual differences between
          Europe and the United States, we used the case studies to analyze
          the commonalities in the content and methods of delivering
          services in the home, which were similar in many respects in all
          locations visited.
 
          HHS also suggested that a more thorough discussion of the pros
          and cons of building home-visiting programs around public health
          nursing would have been helpful.  We agree that this approach may
          have merit for some communities and some objectives.  But the
 
                                         68
 
 
 
 
          public health nurse is only one model of home visiting; its focus
          on public health services delivered by professional nurses may be
          ill suited for other early intervention programs with differing
          objectives.  The key, as Education commented, is that states and
          local providers should have the flexibility to decide which
          mechanisms and settings are appropriate to meet the individual
          needs of the children they serve in their communities.
 
          We have incorporated the departments' technical comments into our
          report where appropriate.
 
 
 
                                         69
 
 
 
          APPENDIX I                                             APPENDIX I
 
 
                            DESCRIPTION OF THE EIGHT HOME-
                            ------------------------------
                            VISITING PROGRAMS GAO VISITED
                            -----------------------------
          This appendix provides programmatic and administrative details
          about the eight home-visiting programs GAO visited in the United
          States and Europe.  The programs are presented in order of length
          of existence, with the U.S. programs first.  Each description
          includes the following:
 
          -- A background section, which highlights the history of the
             program, its goals and objectives, and the target population.
 
          -- A services and activities section, which describes the
             services provided in the home and the type of service
             provider.
 
          -- A results section, which describes evaluation efforts and
             results.
 
          -- A section describing the program's funding, costs, and
             benefits.
 
          -- A section describing officials' views about the program's
             future.
 
 
 
                                         70
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          CENTER FOR DEVELOPMENT, EDUCATION, AND NUTRITION
          ------------------------------------------------
          Table I.1:  Program Profile:  Center for Development, Education,
          and Nutrition (CEDEN)
 
          Geographical areas served:              Austin and Travis County,
                                                  Texas
 
          Goals/objectives:                       Prevent/reverse
                                                  developmental delay;
                                                  promote family self-
                                                  sufficiency
 
          Administrative agency:                  Private, nonprofit
 
          Service delivery method:                Home visiting, group
                                                  meetings
 
          Target population:                      Developmentally delayed
                                                  children up to 60 months
                                                  of age and their families
 
          Number and timing of intervention:      24-34 consecutive weekly
                                                  visits after enrolling
 
          Home visitor qualifications:            College degree, 3 years'
                                                  experience in child
                                                  development preferred
 
          Supervisory characteristics:            College degree, home
                                                  visitor experience
 
          Number of home visitors:                6
 
          Clients served:                         250 children in 1988
 
          Fiscal year 1989 funding:               $441,134
 
          Evaluation results:                     Improvement in mental and
                                                  physical development,
                                                  health, parent-child
                                                  interaction, and home
                                                  environment
 
          Background
          ----------
          The Center for Development, Education, and Nutrition, founded in
          Austin, Texas, in 1979, is a private, nonprofit research and
          development center that provides educational and human services
          to children with developmental deficiencies and to their parents.
 
                                         71
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          CEDEN's primary goals are to (1) prevent or reverse developmental
          delay in children, thereby promoting and strengthening their
          intellectual, physical, social, and emotional development; (2)
          help their parents to plan for, achieve, and maintain self-
          sufficiency; (3) improve or maintain an acceptable home
          environment; (4) improve or maintain the health care and
          nutritional status of program children; and (5) improve parent-
          child interaction.
 
          CEDEN's founder and executive director conducted a needs
          assessment of low-income families in East Austin, home to many of
          the city's poorest Hispanic families.  From this, she ascertained
          that their highest priority of stated needs was for services to
          improve child and family development.  CEDEN originally served
          primarily low-income Hispanic children and women who lived in the
          Hispanic areas of Austin.  Over the years, it expanded its
          target population to include all ethnic and cultural backgrounds
          and all of Travis County, Texas, which includes the city of
          Austin.
 
          CEDEN targets infants and young children up to 60 months of age
          who are either developmentally delayed or at high risk for being
          so, due to biological or environmental circumstances.  Infants
          and young children up to 24 months of age receive priority
          because research indicates that children who are developmentally
          delayed should be reached by age 3.
 
          CEDEN is governed by a 20-member board of directors.   The
          executive director is responsible for overall management and
          administration.  A program coordinator oversees service delivery
          and supervises the six home visitors, referred to as home parent
          educators.
 
          Program Services and Activities
          -------------------------------
          Services are delivered through three programs: (1) the Parent-
          Child Program, which focuses on improving infant and child
          development; (2) the Pro-Family Program, which concentrates on
          teaching parenting skills and developing support groups; and (3)
          the Family Advocacy Program, which helps needy families to become
          self-sufficient.  Most services are delivered through the Parent-
          Child Program, while the other two programs complement it by
          ensuring that the family's basic needs, such as food, shelter,
          and clothing, are met.
 
          Home visiting, along with monthly group meetings, is the primary
          service delivery method for Parent-Child Program services.  The
          home parent educators must have college degrees, preferably have
          3 years' experience in child development, and are expected to
          establish a rapport with their clients.  They receive 2 weeks of
 
                                         72
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          preservice classroom training and 1 month of on-the-job training.
          Some of the topics covered include case assessment, planning, and
          reporting.  They also receive in-service training about every 2
          weeks.  The training, which lasts from 30 minutes to 4 hours,
          covers various subjects, such as stress management, health
          education, child abuse, and alcoholism.  Their supervisor, the
          program coordinator, has an educational background in language,
          child development, and psychology.
 
          After enrolling in the program, each family receives 24 to 34
          consecutive weekly home visits.  Before beginning these visits,
          the CEDEN staff and the family prepare an individual development
          plan for the child and for the family.
 
          CEDEN has an Infant Stimulation Curriculum, which describes
          various activities for each area of child development.  Other
          services include providing health and nutrition information and
          nutritional and diet analyses, improving the home environment,
          and making health and related social service referrals.  The home
          parent educators use the curriculum, the results of preentry and
          mid-program tests, and the individual and family development
          plans to plan each visit.  They use a structured approach to
          ensure that the program's goal and objectives are achieved.
          However, the program is flexible because the family's needs will
          determine which services are provided and which infant
          stimulation and child development activities will be used.
 
          During the home visit, the home parent educator asks children to
          perform certain activities, depending on their developmental
          needs.  She also encourages the parents to interact in a
          prescribed manner with their children in order to maintain the
          progress made through participation in the program.  In addition,
          she may refer the family for medical and social services, an
          important program component.
 
          Program Results
          ---------------
          CEDEN collects and compares specific information for all program
          clients as well as a nonequivalent control group.  The outcome
          measures relate to mental and physical development, health,
          parent-child interaction and home stimulation, and the home
          environment.  Based on program evaluations, the program has
          helped clients in all the measured areas.  For example, at
          program entry, 45 percent of the infants have cognitive and motor
          development delays.  During each program year, this has been
          reduced to 15 percent or less.  At entry, 20 percent of the
          houses are unclean, 21 percent are unsafe, and 26 percent are
          dark and depressing.  At exit, 69 percent of the families
          improved their home environment in one or more of these areas.
 
 
                                         73
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          Program Funding, Costs, and Benefits
          ------------------------------------
          During 1989, CEDEN received about $441,000 from several sources,
          including about $255,000 from federal, state, and local
          governments; $58,000 from nongovernmental grants; and $101,000
          from foundations.  The cost of an average CEDEN home intervention
          in 1984-85, the most current year for which information was
          available, was about $1,095 per client.
 
          Program officials have not conducted a cost-effectiveness
          evaluation for their primary goal of preventing or reversing
          developmental delay.  However, program officials believe that in
          the long run, the need for and therefore the cost of special
          education for children will be reduced through the prevention and
          reversal of developmental delay.
 
          Program Outlook
          ---------------
          CEDEN operated with about $85,000 less in 1989 than in 1988.
          However, due to CEDEN's diverse funding base, this loss did not
          have a major impact on services.  The executive director is
          applying for several more grants and, based on past experience,
          is confident that the program will receive additional funding.
 
          In 1988, CEDEN served about 250 children of an estimated 3,900
          to 4,900 target population.  The executive director would like
          to hire additional home parent educators to serve more families.
 
 
 
 
                                         74
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          RESOURCE MOTHERS FOR PREGNANT TEENS
          -----------------------------------
          Table I.2:  Program Profile:  Resource Mothers for Pregnant Teens
 
          Geographical areas served:              16 rural counties in
                                                  South Carolina
 
          Goals/objectives:                       Reduce infant mortality
                                                  and low birthweight
 
          Administrative agency:                  State and local health
                                                  departments
 
          Service delivery method:                Home visiting
 
          Target population:                      Pregnant teens and teen
                                                  mothers
 
          Number and timing of intervention:      Monthly 1-hour prenatal
                                                  visits; 1-hour bimonthly
                                                  postnatal visit up to age
                                                  one
 
          Home visitor qualifications:            High school diploma;
                                                  ability to establish a
                                                  rapport
 
          Supervisory characteristics:            Master's degree in social
                                                  work
 
          Number of home visitors:                16
 
          Clients served:                         Over 1,300 from July 1986
                                                  through February 1988
 
          Fiscal year 1989 funding:               $521,351
 
          Evaluation results:                     Reduced the number of low
                                                  birthweight babies;
                                                  increased the receipt of
                                                  prenatal care
 
          Background
          ----------
          The South Carolina Resource Mothers for Pregnant Teens program
          was developed in 1980 to deal with the state's high infant
          mortality rate, among the nation's highest for the past several
          years.  The program's goal is to reduce the mortality and
          morbidity of infants born to adolescents and to improve the
          health and parenting activities of those adolescents.  The
 
                                         75
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          program initially targeted teenagers 17 years of age and under,
          pregnant with their first baby. The program now serves 18-year-
          olds and teens who have had more than one child.  The teens must
          live in 1 of 16 rural counties that program officials have
          identified as having pregnancy rates and poor birth outcomes for
          teenagers that exceed the state's rates.  The program targeted
          teenagers because they have a higher percentage of low
          birthweight infants.
 
          The Resource Mothers program was developed under the direction of
          the Bureau of Maternal and Child Health within the South
          Carolina Department of Health and Environmental Control and a
          licensed clinical psychologist.  They decided that the program
          would address the social, educational, and health needs of the
          teens, and that services would be delivered through home visits
          and referrals to other agencies.  The home visitors, referred to
          as Resource Mothers, would be women from the same community in
          which the teens lived, primarily because they believed teens
          would open up to them more readily than to a social worker or
          nurse.
 
          Originally, the program was a research project jointly managed by
          the Medical University of South Carolina, McLeod Regional Medical
          Center, Pee Dee Health Education Center, and the Pee Dee 1 Health
          District.  The Bureau of Maternal and Child Health began
          administering the program in 1985.
 
          The state coordinator for the Resource Mothers program has
          primary responsibility for administering it.  The district
          coordinators, one in each of the four health districts in which
          the program operates, administer the program at the local level.
          They supervise the 16 resource mothers and report to the state
          coordinator.  The district coordinators and resource mothers are
          employees of the local health department operated by the
          Department of Health and Environmental Control.
 
          Program Services and Activities
          -------------------------------
          The Resource Mothers program has many objectives that address
          the program's goals of decreasing infant mortality and improving
          health and parenting activities of adolescents.  These
          objectives cover many medical, social, and educational outcomes
          that can affect low birthweight, the baby's health, and the
          teen's future.  They include, among others, early entry into
          prenatal care, gaining the recommended amount of weight during
          pregnancy, age-appropriate infant clinical visits and
          immunizations, developing parenting skills, family planning, and
          entry into job training.  The primary service delivery strategy
          is home visits made by resource mothers.
 
 
                                         76
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          The resource mothers fulfill five roles: teacher, facilitator,
          role model, reinforcer, and friend.  They are women from the
          local community who have high school degrees and an ability to
          establish rapport with teens.  The first resource mothers
          received 6 weeks of preservice training; those hired when the
          program expanded received 3 weeks.  The training covered several
          subjects, including stages in a pregnancy, proper nutrition,
          labor and delivery, parenting skills, home-visiting techniques,
          and the local service provider network, as well as going on some
          home visits.  New resource mothers are trained by the district
          coordinators, who have master's degrees in social work.  All
          resource mothers receive in-service training at the state and
          local level covering various topics, such as domestic violence
          and stress management.
 
          The home visits are highly structured, with specific goals and
          learning objectives for each visit, depending on the month of
          pregnancy or the infant's age.  The resource mothers, however,
          have flexibility to deal with each teen's particular needs during
          each visit.  Services are offered beginning in the first
          trimester of pregnancy, although not all teens enter the program
          at that point.  The resource mothers visit each teen at least
          monthly during pregnancy, daily in the hospital after delivery,
          and every 2 months during the baby's first year of life.
 
          During pregnancy, the resource mothers emphasize the need for
          early and regular prenatal care and for preventing or reducing
          certain risk factors, including smoking, alcohol or drug use, and
          poor nutrition.  After delivery, they emphasize appropriate
          infant feeding, immunizations, and well-child visits, and teach
          and reinforce positive parenting skills.  The resource mothers
          also refer the teens to other service providers to ensure that
          their medical and social needs, such as adequate food and
          housing, are met, and they reinforce what the teens are told by
          their health care providers.
 
          Program Results
          ---------------
          Based on an evaluation by Dr. Henry C. Heins and others, the
          program has positively affected the incidence of low birthweight
          among teens and increased the number of teens receiving adequate
          prenatal care.  Completed in 1986, the study compared teens who
          received visits from resource mothers to teens who did not, and
          showed that 10.6 percent of the visited teens had low birthweight
          babies compared to 16.3 percent of nonvisited teens, and 82
          percent of visited teens received adequate prenatal care compared
          to 64 percent of nonvisited teens.  The program was being
          evaluated again during our visit, but results were not
          available.
 
 
                                         77
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          A second evaluation, conducted by the South Carolina Bureau of
          Maternal and Child Health, showed that the program met its
          objectives of 50 percent of the teens enrolling in school or job
          training and 80 percent not becoming pregnant for 1 year after
          giving birth.  The program did not meet its objectives of 85
          percent of the teens gaining the recommended weight during
          pregnancy, 90 percent enrolling in family planning clinics, 16
          percent breast-feeding their babies, and 90 percent of the
          infants receiving age-appropriate clinical visits and
          immunizations.  Because of data collection difficulties, program
          officials were unable to determine if the program met its
          objectives related to parenting skills, reducing health risks,
          and increasing knowledge about health behaviors.
 
          Program Funding, Costs, and Benefits
          ------------------------------------
          The program was originally funded by a Robert Wood Johnson
          Foundation grant awarded to the Medical University of South
          Carolina.  When the state began administering the program in
          1985, the program was funded by a 3-year federal Special Projects
          of Regional and National Significance grant, and in fiscal year
          1987, the state added some state funds to the program.  During
          fiscal year 1989, the program received $167,998 in state funds
          and $353,353 in federal MCH block grant funds.
 
          During the same year, the estimated cost for one resource mother
          was $15,715, which included salary, fringe benefits, and
          transportation.  In 1987, the cost of supporting one low
          birthweight infant in a neonatal intensive care unit was $13,616.
          Since program evaluations show that teens visited by Resource
          Mothers have fewer low birthweight babies, program benefits
          exceeded program costs.
 
          Program Outlook
          ---------------
          The Resource Mothers program is currently funded with state and
          MCH block grant funds.  State officials are exploring the use of
          Medicaid funds as well.  Program officials are confident the
          state legislature will continue to support this program because
          there is strong evidence that it makes a difference.  The program
          will continue to operate in the same 16 rural counties, and
          program officials think that the program will eventually operate
          statewide.
 
 
 
 
 
 
 
 
                                         78
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          ROSELAND/ALTGELD ADOLESCENT PARENT PROJECT
          ------------------------------------------
          Table I.3:  Program Profile:  Roseland/Altgeld Adolescent Parent
          Project (RAPP)
 
          Geographical areas served:              Roseland and Altgeld
                                                  communities, Chicago
 
          Goals/objectives:                       Decrease negative
                                                  outcomes associated with
                                                  teen pregnancy; decrease
                                                  potential infant
                                                  mortality and morbidity;
                                                  and increase healthy
                                                  family functioning
 
 
          Administrative agency:                  Catholic Charities' Arts
                                                  of Living Institute
 
          Service delivery method:                Home visiting and group
                                                  support meetings
 
          Target population:                      Teen and pregnant mothers
                                                  age 11-20
 
          Number and timing of intervention:      One prenatal visit;
                                                  weekly until baby is 3
                                                  months old
 
          Home visitor qualifications:            Bachelor's degree
                                                  preferred but not
                                                  required
 
          Supervisory characteristics:            Master's degree preferred
                                                  but not required
 
          Number of home visitors:                5
 
          Clients served:                         160-175 per year
 
          Fiscal year 1988 funding:               $327,271
 
          Evaluation results:                     No formal evaluation
 
          Background
          ----------
          The Roseland/Altgeld Adolescent Parent Project in Chicago serves
          pregnant and parenting teenagers and their babies.  RAPP's goal
          is to decrease the negative social, health, and economic
 
                                         79
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          consequences of adolescent pregnancies by providing or assisting
          clients to obtain comprehensive community based-services.  To
          accomplish this goal, the program has several objectives, which
          include:  (1) decreasing potential infant mortality and
          morbidity, child abuse and neglect, and other negative
          consequences associated with adolescent pregnancies; (2)
          increasing healthy family functioning and well-baby care; (3)
          providing access to the community's resources by networking and
          participating in community organizations and coalitions; and (4)
          decreasing the number of adolescent and repeat pregnancies among
          elementary school girls.
 
          RAPP began in 1980 as a component of the Catholic Charities'
          Arts of Living Institute, a private, nonprofit social service
          agency.  The institute was established in 1973 to address the
          many needs of pregnant adolescents.  Its goal is to decrease
          infant mortality, child abuse and neglect, and teen pregnancies
          by sponsoring projects such as RAPP.
 
          Catholic Charities formed RAPP to serve pregnant and parenting
          females, age 11-20, in the Roseland and Altgeld Gardens
          communities.  Roseland is a neighborhood of older single-family
          dwellings with high unemployment.  Altgeld Gardens, a Chicago
          Housing Authority project composed of row houses, is one of the
          poorest areas in the city.  The program targets teens who live in
          these areas because of the high teenage pregnancy rates and poor
          economic conditions.  Over 25 percent of Roseland's teenage girls
          became mothers, and one-third of the births in Altgeld are to
          teen mothers.
 
          Program Services and Activities
          -------------------------------
          The home visitors provide a variety of services either in the
          home or in group meetings.  These include (1) teaching well-baby
          care, (2) administering the Denver Developmental Screening Test
          to identify developmental problems infants may have, (3)
          providing counseling, (4) observing parent/child relationships,
          and (5) making referrals to other agencies.  Referrals are a
          major component of RAPP because the program cannot provide all
          the assistance the participants need.
 
          The staff includes a project director, a supervisor, five home
          visitors, and a secretary.  The director has a master's degree
          and the supervisor a bachelor's degree in social work.  Three of
          the five home visitors have bachelor's degrees in social work;
          however, a degree is not required.  Most of the home visitors
          come from the communities being served.
 
          Home visitors' preservice training consists of a 1-week
          orientation about the program's goals, objectives, and
 
                                         80
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          procedures.  An experienced home visitor then accompanies them on
          home visits for about 1 month.  They receive regular in-service
          training covering such topics as case management, working with
          volunteers, and documenting client information.
 
          The home visitors use a risk assessment to select the services
          to provide each client.  They followed general guidelines when
          delivering services in the home.  Program officials believe that
          rigid guidelines would be inappropriate because unexpected
          problems may arise, and the home visitors need flexibility to
          address these problems.
 
          The frequency of home visits varies depending on clients' needs.
          The home visitors usually visit their clients once in the home
          during pregnancy and weekly for up to 3 months after the baby is
          born.  In addition, the visitors encourage teens to attend weekly
          support group meetings.  The group follows a curriculum,
          developed by the Minnesota Early Learning Design, to increase
          self-esteem among the participants.  Each meeting has a separate
          theme and involves discussions in which the teens are encouraged
          to share their experiences and feelings.
 
          Program Results
          ---------------
          RAPP does not have a formal evaluation system.  Instead, program
          officials monitor progress toward achieving objectives by
          documenting and summarizing their contacts with and services
          provided to clients.  They send this information to Catholic
          Charities' and the Ounce of Prevention Fund, which use it to
          evaluate progress toward their overall goals.
 
          Program Funding, Costs, and Benefits
          ------------------------------------
          From 1986 to 1989, RAPP received funding from the state of
          Illinois, Catholic Charities, and The Ounce of Prevention Fund, a
          public/private partnership that funds and provides training for
          programs that work with adolescent mothers to foster child
          development.  During 1986-88, total funding increased from
          $194,600 to $327,300.  The state's funding remained stable at
          $55,000 each year.  The Ounce of Preventions Fund's funding also
          remained fairly constant at just over $100,000 each year.
          Catholic Charities funded the remaining costs, which increased
          from $39,000 to $168,200.  Officials had not done a cost/benefit
          analysis and did not have any figures on cost savings or future
          cost avoidance.
 
          Program Outlook
          ---------------
          The program serves 160 to 175 clients per year.  The director
          would like to expand the program to serve more of the target
 
                                         81
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          population and to hire aides to take care of the babies during
          group meetings.
 
 
 
                                         82
 
 
 
          APPENDIX I                                             APPENDIX I
 
          SOUTHERN SEVEN HEALTH DEPARTMENT PROGRAM:  PARENTS TOO SOON AND
          ---------------------------------------------------------------
          THE OUNCE OF PREVENTION COMPONENTS
          ----------------------------------
          Table I.4:  Program Profile:  Southern Seven Health Department
          Program (Parents Too Soon and The Ounce of Prevention Components)
 
          Geographical areas served:              Seven rural counties in
                                                  southern Illinois
 
          Goals/objectives:                       Reduce negative effects
                                                  associated with teen
                                                  pregnancy, such as low
                                                  birthweight of infants
                                                  and the incidence of teen
                                                  pregnancies
 
          Administrative agency:                  Southern Seven Health
                                                  Department
 
          Service delivery method:                Home visiting, workshops
 
          Target population:                      Pregnant and parenting
                                                  teens, ages 10-20
 
          Number and timing of intervention:      Parents Too Soon
                                                  component--monthly
                                                  prenatal visits, and at 6
                                                  weeks and 6 months after
                                                  birth; Ounce of
                                                  Prevention component--
                                                  monthly postnatal visits
                                                  until baby is 12 months
                                                  old, and at 15 and 18
                                                  months of age
 
          Home visitor qualifications:            Bachelor's degree
 
          Supervisory characteristics:            Experienced home visitor
 
          Number of home visitors:                PTS--four; Ounce--three
 
          Clients served:                         65 percent of pregnant
                                                  teens in target area
 
          Fiscal year 1988 funding:               PTS--$224,695; Ounce--
                                                  $90,640
 
          Evaluation results:                     Fewer low birthweight
                                                  infants born to program
 
 
                                         83
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
                                                  participants than
                                                  nonparticipants
 
          Background
          ----------
          The Southern Seven Health Department Program, which provides
          services in seven southern Illinois counties, focuses on (1)
          reducing the negative effects associated with teenage pregnancy,
          (2) securing needed services for clients, and (3) reducing the
          incidence of teenage pregnancy.
 
          The program targets girls and young women, age 10 to 20, who are
          at high risk for negative consequences of pregnancy and
          parenting.  They must reside in the seven counties, which
          encompass a rural area of about 2,000 square miles.
 
          The program is operated by the Southern Seven Health
          Department's Social Services Division.  The division director,
          who reports to the Health Department administrator, administers
          the program and supervises the home visitors.
 
          The program, which began in early 1984, has two components with
          separate staff.  The Parents Too Soon (PTS) component is a state
          program that attempts to deter teenage pregnancy and lessen the
          negative consequences of adolescent pregnancy and childbearing.
          It focuses primarily on pregnant teens during their prenatal
          stage.  Another component is supported by The Ounce of Prevention
          Fund, a public-private entity concerned with healthy child
          development.  The staff of this component provide services to
          teens after their child's birth.  These components are offered
          jointly to maximize the positive pregnancy and parenting outcomes
          for teens enrolled in the program.
 
          Program Services and Activities
          -------------------------------
          To accomplish the program's objectives, the home visitors
          provide a variety of services.  These include (1) teaching
          prenatal and well-baby care, (2) ensuring that the client has a
          medical provider and transportation to get there, (3) providing
          information on family planning, (4) counseling clients about
          infant development and behavior and budgeting and housekeeping,
          and (5) referring clients to other agencies.  The referrals are
          an important program component because referral agencies can help
          the teens with their medical, social, and educational needs.  In
          addition to home visits, the staff provide sex education and
          prenatal workshops.
 
          A multidisciplinary professional staff provides the program
          services.  The staff includes four social workers, two nurses,
          and one nutritionist who make home visits, and one lay person
 
                                         84
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          whose primary responsibility is to help teens to remain in
          school.
 
          New home visitors receive 1 to 2 weeks of orientation about the
          program.  The PTS staff are not required to attend in-service
          training; however, they may attend optional workshops on such
          topics as preterm labor, nutrition, and stress management.  The
          Ounce of Prevention staff attend an annual conference and four
          workshops each year on such topics as nutrition and parenting
          skills.
 
          When a client enrolls in the program, the home visitor does a
          risk assessment to determine the client's needs and develops a
          service delivery strategy to ensure that those needs are met.
          When the client is near delivery, she is transferred to the Ounce
          program and another assessment is done.  To allow for
          flexibility, the home visitors did not follow a structured
          protocol during the home visits.  However, as of January 1990,
          the Ounce required its home visitors to follow a structured
          curriculum that allowed flexibility.
 
          The frequency of home visits varies by program component and the
          client's needs.  However, a general rule is that the PTS staff
          see their clients once a month throughout pregnancy and again
          when the baby is 6 weeks and 6 months of age.  The Ounce home
          visitors see their clients about once a month from the time the
          baby is born until the baby is 12 months old and again at 15 and
          18 months.
 
          Program Results
          ---------------
          The Southern Seven program does not have a formal evaluation
          component.  However, program statistics for 1984-87 show that in
          3 of the 4 years, program participants had fewer low birthweight
          infants than nonparticipants.  In 1987, 2 percent of the
          participants had low birthweight infants, compared to 12.5
          percent of the nonparticipants.
 
          Program Funding, Costs, and Benefits
          ------------------------------------
          The program is funded by the state of Illinois and The Ounce of
          Prevention Fund.  Total funding in fiscal year 1988 was $315,300,
          with 71 percent coming from the state and 29 percent from the
          Ounce.  Officials had not done a cost-benefit analysis and,
          therefore, did not have any figures on cost savings or future
          cost avoidance.
 
          Program Outlook
          ---------------
 
 
                                         85
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          The project director believes that the quality of the program's
          services will suffer if it is not able to retain qualified staff
          to deliver program services.  In order to do so, the program
          needs to offer the home visitors higher salaries.  Thus far,
          neither the state nor The Ounce of Prevention Fund has indicated
          that it will increase program funding.
 
 
 
                                         86
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          MATERNAL AND CHILD HEALTH ADVOCATE PROGRAM
          ------------------------------------------
          Table I.5:  Program Profile:  Maternal and Child Health Advocate
          Program
 
          Geographical areas served:              Detroit
 
          Goals/objectives:                       Promote early use of
                                                  prenatal and child health
                                                  care to improve pregnancy
                                                  outcomes and infant
                                                  health
 
 
          Administrative agency:                  Wayne State University
                                                  Medical School
 
          Service delivery method:                Home visiting
 
          Target population:                      Women enrolled in
                                                  specific prenatal health
                                                  clinics or who had a
                                                  high-risk newborn
 
          Number and timing of intervention:      Up to 21 visits scheduled
                                                  throughout pregnancy and
                                                  until the baby reaches 1
                                                  year of age
 
          Home visitor qualifications:            High school diploma;
                                                  receiving public
                                                  assistance when hired
 
          Supervisory characteristics:            Master's degree in social
                                                  work or registered nurse
 
          Number of home visitors:                21 originally hired; 9 as
                                                  program phased out
 
          Clients served:                         First year--705; second
                                                  year--848
 
          Fiscal year 1989 funding:               $553,000
 
          Evaluation results:                     Available in 1990
 
          Background
          ----------
          The Maternal and Child Health Advocate Program, in Detroit, was a
          home-visiting project with the goal of promoting early and
 
                                         87
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          appropriate use of prenatal and child health care to improve
          pregnancy outcomes and infant health.  The project targeted
          pregnant women enrolled in specific prenatal clinics and women
          with high-risk newborns in the Children's Hospital of Michigan
          neonatal intensive care unit.
 
          The program, begun as a research project in June 1986 and ended
          in October 1989, was administered by Wayne State University
          Medical School's Department of Community Medicine.  The
          department's chairperson, a Department of Pediatrics professor,
          and a Department of Obstetrics and Gynecology professor
          codirected the project.  The staff included a project
          coordinator, who managed the program, and three teams, each of
          which included a supervisor and four home visitors, called
          advocates.  In June 1988, the university's newly created
          Institute of Maternal and Child Health began administering the
          program using the same administrative structure.
 
          Program Services and Activities
          -------------------------------
          The advocates provided case management, referral, and counseling
          services in the home.  Specifically, advocates (1) administered
          assessment questionnaires, (2) counseled mothers regarding
          pregnancy and related issues, (3) identified various resources
          for health needs, and (4) provided referrals for other needs,
          such as transportation, food, and clothing.  The advocates also
          provided emotional support.  The advocates spent much of their
          time making referrals because many of their clients had no
          knowledge of available services and how to access them.
 
          The advocates followed two types of structured protocols while
          conducting home visits.  The first was a needs assessment
          administered at five points between the initial prenatal contact
          and the baby's first birthday.  The assessment covered the
          clients' health, living conditions, and social problems and was
          used to tailor services to the clients' needs.  The second was
          case management guidelines, which described a suggested minimum
          number of visits and the appropriate services to be given at
          various stages.  For example, during the third trimester of
          pregnancy, the visit's focus was on preparing for labor and
          delivery and on using contraceptives after childbirth.  The
          guidelines recommended that each client receive up to 21 visits
          scheduled throughout pregnancy and until the baby was 1 year old.
          The number of visits would depend on when the client entered the
          program.  The advocates could deviate from the protocol to
          address any current crises facing their clients.
 
          Program staff were hired between June 1986 and March 1987, at
          which time home visits began.  The home visitors had to (1) be
          receiving public assistance, (2) have a high school diploma, (3)
 
                                         88
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          work well with others, (4) be Detroit residents, and (5) be
          familiar with the city's social service system.  The program also
          tried to hire persons who were caring and culturally sensitive
          and had good interpersonal skills.  Two of their supervisors had
          master's degrees in social work, and one was a registered nurse.
 
          The home visitors received 6 weeks of preservice training.
          Topics included human growth and development, human enhancement
          skills, community resources and how to use them, and the role of
          a paraprofessional.  They attended monthly in-service training
          covering such topics as parenting resources and skills and AIDS
          and pregnancy.
 
          Program Results
          ---------------
          Program effectiveness was determined by comparing clients
          receiving full program services to two other groups.  The three
          groups were (1) a home visitor group who received regular home
          visits until their infants' first birthday, (2) a research
          control group who received occasional visits, and (3) a
          comparison group who received no visits.  Evaluation results were
          to be available in 1990.
 
          Program Funding, Costs, and Benefits
          ------------------------------------
          The program received funding from the Michigan Department of
          Health, the Ford Foundation, and VISTA during its 40-month
          existence.  During this period, the state provided $877,000 used
          primarily for services, and the Ford Foundation provided $509,000
          used primarily for evaluation during the first 2 years.  VISTA
          provided funds that were used to pay subsistence allowances
          instead of salaries to the home visitors.  Increased state
          funding during the third year was used to pay the home visitors a
          salary.  Program officials did not have any data on cost savings
          or future cost avoidance.
 
          Program Outlook
          ---------------
          The Maternal and Child Health Program ended in October 1989.  At
          that time, the Institute of Maternal and Child Health began a new
          prenatal/postnatal home-visiting project.  The new program was
          designed to reach pregnant women who are not getting prenatal
          medical care by emphasizing community participation.  To do this,
          program officials planned to increase the presence of supportive
          community personal networks for women with children and establish
          a local advisory board consisting of health and social service
          providers, community leaders, and residents.  The new project
          focuses on pregnant women and parents of young children from four
          communities in Detroit's Eastside.  The project is funded by HHS
          and the Michigan Department of Public Health.
 
                                         89
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          CHANGING THE CONFIGURATION OF EARLY PRENATAL CARE
          -------------------------------------------------
          Table I.6:  Program Profile:  Changing the Configuration of Early
          Prenatal Care (EPIC)
 
          Geographical area served:               Providence
 
          Goals/objectives:                       Improve pregnancy
                                                  outcomes, health care and
                                                  coping skills; reduce low
                                                  birthweight
 
 
          Administrative agency:                  Rhode Island Department
                                                  of Health
 
          Service delivery method:                Home visiting
 
          Target population:                      Inner-city, low-income,
                                                  high-risk women
 
          Number and timing of intervention:      8-10 weekly visits during
                                                  20-30-week gestation
                                                  period
 
          Home visitor qualifications:            Bachelor's degree in
                                                  nursing; home-visiting
                                                  experience
 
          Supervisory characteristics:            Master's degree in
                                                  nursing; home-visiting
                                                  experience
 
          Number of home visitors:                2
 
          Clients served:                         280
 
          Total program funding:                  $459,545
 
          Evaluation results:                     Not completed
 
          Background
          ----------
          The Changing the Configuration of Early Prenatal Care project in
          Providence was a preventive public health program.  The project
          addressed risk factors amenable to change among women at high
          risk for having low birthweight infants.  EPIC's goal was to
          improve the pregnancy outcomes for high-risk, inner-city women
          through mid-pregnancy prenatal care home intervention.  To
          accomplish this goal, the project sought to (1) increase the
 
                                         90
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          average number of prenatal doctor visits from 8 to 10; (2)
          improve the nutritional status, lifestyle behavior, and health
          care utilization of clients served; and (3) reduce the incidence
          rate of low birthweight by 30 percent among the target
          population.
 
          Services were provided to inner-city, low-income, high-risk
          pregnant women who registered for prenatal care during March
          1987 and June 1989 at two inner-city Providence Maternal and
          Child Health clinics.  They also had to (1) be less than 20 weeks
          pregnant, (2) live in a census tract with a higher than average
          percentage of low birthweight babies, and (3) agree to
          participate in the project.
 
          EPIC, begun as a research and development project in October
          1986, was administered by the Rhode Island Department of
          Health's Division of Family Health.  The division's special
          projects and evaluation section chief was the EPIC project
          director with responsibility for administering and evaluating the
          program.  The Department of Health contracted with the Visiting
          Nurses Association, Inc. (VNA), for two nurses and a supervisor
          to provide EPIC services.
 
          Program Services and Activities
          -------------------------------
          EPIC provided services in five broad areas: (1) medical prenatal
          services, (2) other medical and social community services, (3)
          substance abuse, (4) nutrition, and (5) coping with stress.
          Services were provided through 8 to 10 weekly home visits between
          the 20th and 30th weeks of pregnancy and referrals to other
          providers.  Based on observations, questions, and the woman's
          medical background, the nurses determined her knowledge,
          resources, and support as they related to each of the five
          service areas.  The nurses then placed each woman into one of
          three modules for each service area, depending on the intensity
          of need.  They also used interpreters to assist in providing
          services to their non-English-speaking clients, including
          Hispanic and Southeast Asian women.
 
          The nurses followed a protocol during the home visits; however,
          they could deviate from it if the clients had other concerns
          that needed to be addressed.  During the home visits, the nurses
          provided information that specifically related to the women's
          needs.  Examples included the effects of substance abuse on fetal
          development, how to apply for food stamps, and the importance of
          eating well-balanced meals.  The nurses also referred the program
          participants to other agencies that could provide services that
          the EPIC program did not provide, such as drug counseling and
          Medicaid.  No services were provided after the child was born.
 
 
                                         91
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          The EPIC nurses had bachelor's degrees in nursing, had several
          years of home-visiting experience, and were selected because they
          were compassionate, honest, and able to easily establish a
          rapport with others.  The supervisor had a master's degree in
          nursing and extensive home-visiting experience.  Since the nurses
          had prior home visiting experience and were knowledgeable about
          the local service provider network, the program did not include
          formal preservice or in-service training.
 
          EPIC provided services from March 1987 through June 1989.  Of the
          1,160 women to whom the program was offered, 559 agreed to
          participate.  Half of these women received home visits, while the
          other half served as a control group for evaluation purposes.
 
          Program Results
          ---------------
          Program officials used a randomized controlled trial research
          design to evaluate the program.  At the time of our visit in June
          1989, formal evaluation was just beginning.  Consequently,
          conclusions had not been drawn regarding whether the program had
          achieved its three major goals.  However, the preliminary
          evaluation results indicated that the project had positively
          affected the pregnancy or lives of the women who received home
          visits.  For example, preliminary posttest evaluation results
          showed a 55-percent increase in the number of women enrolled in
          WIC for program participants in comparison to a 38-percent
          increase for the control group.  The program director planned to
          complete the evaluation by spring 1990.
 
          Program Funding, Costs, and Benefits
          ------------------------------------
          EPIC was funded entirely by a 3-year $459,545 federal SPRANS
          grant.  Based on VNA estimates, the average intervention cost
          $23.30 per hour.  This included salaries, benefits, and
          transportation expenses for the nurses, escorts, and
          interpreters, but not overhead or supervisory expenses incurred
          by VNA or evaluation expenses incurred by the state. The total
          VNA cost per visit including overhead depended on the number of
          visits made each day.  While the program operated, about three
          visits were made each day; VNA estimated that the average cost
          was $87 per visit.
 
          Program officials did not have any figures on cost savings or
          future cost avoidance.  This information was to be developed as
          part of the program evaluation.
 
          Program Outlook
          ---------------
          The program ceased to function in June 1989.  The project
          director speculated that if evaluation results were positive, the
 
                                         92
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          program might be funded with state funds or federal MCH block
          grant funds.  In the interim, no attempts were being made to
          continue EPIC services.  Evaluation results were also to be used
          to refine the program's objectives and services, if necessary.
          If the program were continued, it would be administered by the
          Department of Health's Preventive Services Section, which would
          integrate EPIC services with other state-funded services.  The
          department would continue to contract with VNA for delivery of
          program services.
 
 
 
                                         93
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          GREAT BRITAIN'S HEALTH VISITOR PROGRAM
          --------------------------------------
          Table I.7:  Program Profile:  Great Britain's Health Visitor
          Program
 
          Geographical areas served:              Great Britain (England,
                                                  Scotland, Wales, and
                                                  Northern Ireland)
 
          Goals/objectives:                       Promote sound mental,
                                                  physical, and social
                                                  health of children by
                                                  educating families
 
          Administrative agency:                  District health
                                                  authorities
 
          Service delivery method:                Home visiting
 
          Target population:                      Children from birth
                                                  through age 5
 
          Number and timing of intervention:      One prenatal visit plus
                                                  five visits from birth
                                                  through age 5
 
          Home visitor qualifications:            Registered nurses with
                                                  special graduate-level
                                                  education
 
          Supervisory characteristics:            Previous health-visiting
                                                  experience
 
          Number of home visitors:                One health visitor per
                                                  3,000 people
 
          Clients served:                         All children in Great
                                                  Britain
 
          Fiscal Year 1989 funding:               Not available
 
          Evaluation results:                     No evaluation done
 
          Background
          ----------
          Home health visiting in Great Britain began in 1852, when
          members of the Manchester and Saltford Ladies Sanitary Reform
          organization began to visit poor families in their homes to
          improve their health knowledge and practices.  By 1905, 50 areas
          employed health visitors.  The 1907 Notification of Births Act
 
                                         94
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          established a procedure to notify responsible authorities,
          including health visitors, when a baby was born; this became
          mandatory in 1915.
 
          The goal of health visiting in Great Britain is to promote
          health and to prevent mental, physical, and social ill health in
          the community.  The primary focus is on maternal and child health
          care, and the expected outcome is reduced infant mortality and
          morbidity rates.
 
          All British residents are eligible for health-visiting services;
          however, the health visitors target children from birth through
          age 5.  The program further targets children who are at risk due
          to inadequate housing and improper nutrition.
 
          In Great Britain, the Health Ministers in England, Wales,
          Scotland, and Northern Ireland have responsibility for health
          services.  In England, there are 14 regional health authorities
          and 191 district health authorities.  The district authorities
          employ health visitors who, together with general practitioners
          and midwives, make up a primary health care team.  The general
          practitioner and the midwife provide prenatal care at community
          health clinics, while the health visitor provides postnatal
          services in the home.
 
          Program Services and Activities
          -------------------------------
          During a health visit, the focus is on health promotion and
          education, immunization, and screening and surveillance of
          infants.  Education is the primary method health visitors use to
          help families make sound, informed decisions.  Specifically, the
          health visitors emphasize such things as breast-feeding, infant
          immunizations, accident prevention, and appropriate health care.
          The health visitors also monitor the child's development so that
          potential problems, such as poor hearing, can be identified and
          addressed as soon as possible.  They also make necessary
          referrals for medical care or social services.
 
          The health visitors follow general guidelines when delivering
          services.  Typically, six home visits are made per pregnancy: one
          prenatal visit when the health visitor describes her role and
          available services to the family and five postnatal visits before
          the child enters school.  During each visit, the health visitors
          have flexibility to address any unanticipated problems.  Each
          child also receives hearing and mobility screening tests in a
          clinic at about 7 to 9 months of age and another clinic screening
          of vision, hearing, social skills, and physical and emotional
          development at 2-1/2 to 3 years of age.
 
 
 
                                         95
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          In most cases, the health visitor independently provides the
          advice, guidance, and education that families need.  However, she
          has a close working relationship with other community support
          agencies that handle psychological, social, and legal problems
          that she is not qualified to handle.
 
          All health visitors are registered general nurses and have
          completed a postgraduate health visitors course that requires 51
          weeks of academic and practical training.  The curriculum
          includes such topics as human growth and development and social
          policy and administration.  After completing the course, health
          visitors are given a small caseload under supervision.  After
          certification, the health visitor receives in-service training
          from her employing health authority.  The training generally
          consists of refresher courses and seminars.
 
          Senior nursing officers, who are experienced health visitors,
          supervise the health visitors.  They usually supervise about 25
          visitors, but this varies by district.  However, the health
          visitors receive little direct oversight from supervisors.
 
          Program Results
          ---------------
          Program officials have not formally evaluated the effectiveness
          of health visiting.  However, public health officials believe the
          effects of health visiting are positive.
 
          Program Funding, Costs, and Benefits
          ------------------------------------
          In Great Britain, total health service expenditures increased by
          229 percent from $14 billion in 1978 to $46 billion in 1989, not
          considering inflation or currency fluctuations.#44  Health
          officials could not tell us the amount of health service
          expenditures spent on health visiting and did not know how much
          health visiting cost.  They also had not done a cost-benefit
          analysis and did not have any figures on cost savings or future
          cost avoidance.
 
          Program Outlook
          ---------------
          Because of rising costs and increasing demands for health
          services, the British Government is beginning to demand more
          accountability.  The prospect of productivity-oriented reforms in
          the National Health Service will cause all health professions to
          begin determining the costs and outcomes of their services.  To
          this end, program officials are beginning to develop management
 
 
        44The annual average exchange rate for the pound sterling for
          1988 was $1.780805=1 pound.
 
                                         96
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          information systems to monitor the amount and type of health
          visitor services delivered and to measure their success in
          meeting the program's objectives.
 
 
 
                                         97
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          DENMARK'S INFANT HEALTH VISITOR PROGRAM
          ---------------------------------------
          Table I.8:  Program Profile:  Denmark's Infant Health Visitor
          Program
 
          Geographical area served:               273 of 277 municipalities
 
          Goals/objectives:                       Reduce infant mortality
                                                  by promoting the health
                                                  and well-being of
                                                  children
 
          Service delivery method:                Home-visiting and
                                                  parenting classes
 
          Target population:                      Children through age 6
 
          Number and timing of intervention:      Tailored to clients'
                                                  needs
 
          Home visitor qualifications:            Professional nurse who
                                                  completed an advanced
                                                  program in public health
                                                  nursing
 
          Supervisory characteristics:            Public health nurse
 
          Number of home visitors:                On average, 1 per 120
                                                  children
 
          Clients served:                         90 percent of all infants
                                                  as of 1976
 
          Fiscal year 1989 funding:               Not available
 
          Evaluation results:                     No evaluation done
 
          Background
          ----------
          Home health visiting in Denmark began in 1932 as a pilot program
          in response to the country's high infant mortality rate.  Four
          nurses went to four geographical areas in Denmark and visited
          each newborn at least 12 times during the first year of life.  In
          1937, after 6 years of what the government characterized as
          positive findings, the Danish Parliament passed a law allowing
          municipalities in Denmark to employ public health nurses as
          health visitors.  The law did not make the service compulsory,
          but the government offered to subsidize 50 percent of the health-
          visiting costs for municipalities that chose to participate.
 
 
                                         98
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          Additional legislation was passed in 1946, 1963, and 1974 to
          strengthen the original law.
 
          The purpose of home health visiting in Denmark, hereafter
          referred to as health visiting, is to promote the health and
          well-being of children.  The health-visiting program focuses on
          the preventive mental, social, and environmental factors that
          combine to influence the behavior of mothers and their children.
          The program targets children from birth to age 6.
 
          Health visiting in Denmark is a component of a preventive health
          care system to which all citizens have free access.  As of 1985,
          273 of the 277 municipalities in Denmark employed a health
          visitor.  Individuals and families can refuse health-visiting
          services, but less than 2 percent do so.
 
          Health visitors are employed at the municipal level by the
          Director of Social and Health Administration and belong to a
          primary health team that includes general practitioners and
          midwives.  The director oversees the health visitor services.
          For the most part, the health visitors function independently,
          planning and scheduling their own work.  Most municipalities are
          small and do not employ a health visitor supervisor.
 
          Program Services and Activities
          -------------------------------
          The health visitors provide many services designed to influence
          parental behavior and decrease children's health problems.  They
          perform routine health checkups for infants and answer new
          mothers' questions about feeding, diapering, illnesses, and the
          baby's development.  They also test the child for sight, hearing,
          and motor development.  In addition, nurses help mothers with
          other needs, including obtaining transportation to a clinic or
          assisting with domestic problems and stress management.  To
          supplement the health visits, some municipalities offer parenting
          classes and programs for the mother, such as parent group classes
          and open houses.  During the classes, the parents and health
          visitors discuss such topics as nutrition, diet, and infant
          stimulation.  Open houses are held once a week at the health
          visitor's office, where mothers and their babies come to interact
          with one another.
 
          A basic principle of Denmark's overall health policy is the
          coordination and cooperation of various health and social
          services.  The health visitor is responsible for establishing
          continuity in preventive, curative, and outreach services for the
          families served.  The health visitor fosters cooperation with a
          host of other agencies, because while highly skilled, the health
          visitor is not equipped to handle all the problems that might be
          encountered, such as alcoholism and child abuse.
 
                                         99
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
 
          The health visitor has flexibility in conducting the home
          visits.  A standardized program delivery strategy is followed;
          however, each visit is tailored to address conditions prevailing
          at that time.  The number and frequency of visits is based on the
          health visitor's assessment of the physical, social, and
          environmental conditions of the child and family.  However, a
          child and family who are not at risk will receive five visits
          during the child's first year.
 
          To become a health visitor, a person must (1) be a professional
          nurse, (2) complete an advanced program in public health nursing,
          and (3) pass an exam covering the principles and practices of
          public health nursing and organization and administration.  The
          health visitors do not attend scheduled inservice training;
          however, each year, they may attend a Danish Nurses Organization-
          sponsored conference.  Topics covered include the latest health
          prevention strategies, psychology, and communications.
 
          Program Results
          ---------------
          Since the pilot program in the 1930s, health visiting has not
          been evaluated to measure its effectiveness.  Public health
          officials in Denmark believe that health visiting is an important
          part of preventive health care and that it promotes wellness by
          developing healthier children, which leads to a lower infant
          mortality rate.
 
          Program Funding, Cost, and Benefits
          -----------------------------------
          In 1985, Denmark spent $4.9 billion,#45 or 5.5 percent of its
          gross national product, on public health services, including
          health visiting.  Program officials do not collect data on the
          cost of health visiting services.  They have not done a cost-
          benefit analysis and had no figures on cost savings or future
          cost avoidance.
 
          Program Outlook
          ---------------
          Raising health standards through preventive health is of great
          importance in Denmark.  Because of this, health visiting will
          continue to be a government priority.  However, health visiting
          may change in the near future.  In 1987, the Danish Minister of
          Health proposed consolidating all health care legislation.  This
          action, which may take effect in January 1991, may make health
          visiting mandatory.  The legislation may also allow the
 
 
        45The annual average exchange rate for the Danish kroner for
          1988 was $1.00=6.72809 kroner.
 
                                         100
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
          municipalities to hire professionals other than nurses, such as
          social workers, to provide health-visiting services.
 
 
 
                                         101
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
 
 
                            WHAT HAPPENS ON A HOME VISIT?
                            -----------------------------
          GAO staff accompanied home visitors at every site we visited.
          The following descriptions illustrate the variety of situations
          encountered by home visitors.
 
          AIKEN COUNTY, RURAL SOUTH CAROLINA
          ----------------------------------
          Purpose of visit:  To support and educate a teenager close to
          delivery.
 
          Provider:  Paraprofessional, Resource Mothers Program.
 
          The client was 13 years old, 8-1/2 months pregnant, a victim of
          child abuse and, currently, a ward of the state.  The visit took
          place in her grandmother's trailer--where the client had often
          returned when running away from her foster homes.  The home
          visitor had to knock several times and call the client's name
          before the door would open.  The trailer was cluttered and
          cramped, and the young woman was dressed in a windbreaker with
          what appeared to be only a slip beneath it.  The client was not
          feeling well and complained of an aching back.  When the home
          visitor asked if the baby was moving actively, the client
          indicated that she had not felt much movement since her mother
          had kicked her in the stomach during an argument.  Concerned
          about the health of the unborn baby, the home visitor urged the
          client to see her doctor.  Because the baby was almost due, the
          home visitor and the girl discussed contingency plans in case the
          client was alone during labor.  The home visitor reminded the
          girl that she could call 911 if she needed help.  The home
          visitor stressed the importance of good nutrition for the
          remainder of the girl's pregnancy.  The girl promised to call her
          home visitor as soon as the baby was born.
 
          AUSTIN, TEXAS
          -------------
          Purpose of visit:  To work on fine motor, language, and cognitive
          skills with developmentally delayed child.
 
          Provider:  Professional, CEDEN program.
 
          A small apartment was home for the mother, her four children,
          and, periodically, her husband.  Program services were directed
          to the youngest of this Hispanic family--a 26-month-old girl
          with delayed speech development.  The home visitor moved through
          a number of speech, fine motor, and cognitive development
          exercises, including sounds and pictures of animals, bead
          stringing, and puzzles of different shapes and sizes.  The
 
                                         102
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
          mother, 32 years old with a seventh grade education, was included
          in these structured activities.  The mother spoke to the child in
          a mixture of Spanish and English.  The home visitor encouraged
          the mother to speak more often to the child.  Though the child
          had made progress, she was still quite shy and rarely spoke.  She
          would, however, frequently look at the family's visitors and
          smile.  The home visitor was trying to schedule a speech
          assessment for the child at the University of Texas.
 
          ANNA, A SMALL TOWN IN RURAL ILLINOIS
          ------------------------------------
          Purpose of visit:  To educate and support a teen mother.
 
          Provider:  Professional, Southern Seven Program
 
          The teen mother seemed happy to see the home visitor.  Though the
          family--a 17-year-old-mother, her husband, and their 15-month-
          old-child--had just moved into a public housing project the week
          before, their apartment was neat and clean.  The mother was home
          alone with her daughter; her husband was at work.  The home
          visitor covered a number of topics relating both to the child's
          development and the mother's goals.  She checked if the child had
          been immunized and had reached developmental milestones, such as
          feeding and undressing herself.  The mother and home visitor
          discussed positive child discipline practices, such as rewarding
          for good behavior and making the child sit in the corner instead
          of physically punishing her.  The home visitor gave information
          on child development and enrolling the child in Head Start.  They
          discussed birth control methods.  The mother told the home
          visitor she was planning to return to school and planned to keep
          her birth control appointment, since she did not want more
          children.  According to the home visitor, her short-term goals
          were to have the mother pass her high school equivalency exam
          and increase her parenting skills.  The home visitor would like,
          in the long term, to see this mother become more self-confident
          and employed.
 
          ALTGELD GARDENS, A HOUSING DEVELOPMENT IN URBAN CHICAGO
          -------------------------------------------------------
          Purpose of visit:  To discuss the mother's needs, the child's
          development, and the home situation since the last visit.
 
          Provider:  Paraprofessional, RAPP program.
 
          This 19-year-old mother of a 19-month-old daughter had been a
          client of the program for almost 2 years.  The mother had not
          had an easy life.  She had been sexually assaulted by a number of
          family members and forced to leave her family by her mother--who
          had also been a teen mother--when she became pregnant.  After her
          child's birth, the client moved from her aunt's home to a
 
                                         103
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
          boyfriend's, then to a grandfather's in another state, to a
          girlfriend's, and, finally, back to her mother's.  According to
          the client, her life had begun to improve, due in part to RAPP.
          She had started a full-time job, found a baby sitter close to
          home, and planned to enter college in the fall.  Though her
          current living situation still produced problems, finding
          employment had helped.  The home visitor informed the mother
          about sources of financial support for college.  In addition, the
          home visitor gave the mother suggestions for developmental
          activities for the child.  The home visitor would see this client
          again that week at the program's group meeting.
 
          HOLBAEK, A SMALL TOWN IN DENMARK
          --------------------------------
          Purpose of visit:  To check on the status of breast-feeding,
          weigh the child, and respond to the mother's questions.
 
          Provider:  Professional nurse.
 
          This was the home visitor's third visit to a young family with
          their first baby.  The mother was 25 years old and not married to
          the father, a 26-year-old mason.  Their baby was a few weeks old.
          Their home was spacious and well furnished.  The home visitor's
          goal for this visit was to chart the child's growth and
          development and answer any questions of the mother.  After
          weighing the baby and recording her progress, the home visitor
          discussed immunization with the mother, suggesting that the baby
          get her first vaccination soon.  The baby had a skin rash, which
          the home visitor diagnosed as merely dry skin.  She advised the
          mother on preventing such rashes in the future and encouraged
          both parents to attend evening parents' group meetings.  The
          mother asked about her baby's crying patterns.  The home visitor
          reassured her that everything appeared to be normal.  After the
          visit ended, the home visitor told us that would be her last
          visit for a while, since the family was considered a "no-problem"
          household.  Contact with this family would be maintained through
          the parents' group.
 
          MID GLAMORGAN HEALTH DISTRICT, RURAL WALES
          ------------------------------------------
          Purpose of visit:  To physically check children and assess living
          conditions of higher risk families.
 
          Provider:  Professional nurse.
 
          The two families visited were living in trailers in a gypsy
          caravan park.  These nomadic families travel throughout Great
          Britain, parking on vacant or public lands.  This caravan park
          was very dirty and lacked running water.  A water pump was
 
 
                                         104
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
          available down the road.  Both families had troubled histories of
          alcohol, violence, or child abuse.
 
          One family's 6-year-old and 2-1/2-year-old were checked for
          scabies (parasitic mites that burrow under the skin) as a follow-
          up to a clinic visit.  This family had recently lost a third
          child in a hit-and-run accident.  Although the mother did not
          appear to be very receptive to advice, the home visitor felt she
          was making progress because the mother had brought the children
          into the clinic to get treatment.
 
          The second family had seven children and an alcoholic, violent
          father.  The prior year, the father had set fire to their caravan
          with one child still inside, who escaped unharmed.  The home
          visitor spent much of the visit discussing birth control with the
          mother.  According to the home visitor, the mother was
          conscientious and receptive to advice.  This was not the norm,
          however.  In the home visitor's opinion, many gypsy families
          resist authority of any kind.  These families needed to be
          visited more frequently because of their many problems.
 
          OXFORDSHIRE HEALTH DISTRICT, SUBURBAN LONDON
          --------------------------------------------
          Purpose of visit:  To check on the health progress of a toddler.
 
          Provider:  Professional nurse.
 
          The home visitor made a routine visit to an 18-month-old and the
          child's mother, a 23-year-old Indian woman married to an older,
          unemployed man with a heart condition.  The child was
          overweight, so the home visitor spent most of the visit
          discussing proper child nutrition and its importance to normal
          development.  In the opinion of the home visitor, nutrition and
          health issues are often culturally based.  The mother seemed set
          in her ways and might not be open to new influences.  These
          cultural differences presented a problem for home visitors, who
          were trying to ensure that families followed the best modern
          health practices.
 
 
 
 
                                         105
 
 
 
 
          APPENDIX III                                         APPENDIX III
 
                      COMMENTS FROM THE DEPARTMENT OF EDUCATION
                      -----------------------------------------
 
 
                         (Were not converted to ASCII text.)
 
            (To obtain a printed copy of the full report, see the
             instructions on the first page.)
 
 
                                         106
 
 
 
 
          APPENDIX IV                                           APPENDIX IV
                            COMMENTS FROM THE DEPARTMENT
                            ----------------------------
                            OF HEALTH AND HUMAN SERVICES
                            ----------------------------
 
 
                         (Were not converted to ASCII text.)
 
            (To obtain a printed copy of the full report, see the
             instructions on the first page.)
 
 
 
                                         107
 
 
 
 
          APPENDIX V                                             APPENDIX V
                          MAJOR CONTRIBUTORS TO THIS REPORT
                          ---------------------------------
          HUMAN RESOURCES DIVISION, WASHINGTON, D.C.
          ------------------------------------------
          Kathryn G. Allen, Project Director, (202) 275-8894
          David D. Bellis, Project Manager
          Sheila Avruch, Evaluator
          Hannah F. Fein, Writing Specialist
 
          ATLANTA REGIONAL OFFICE
          -----------------------
          Shellee S. Soliday, Deputy Project Manager
          Cheri Y. White, Evaluator
 
          CHICAGO REGIONAL OFFICE
          -----------------------
          Adrienne F. Friedman, Site Senior
          Judith A. Michaels, Evaluator
 
          EUROPEAN OFFICE
          ---------------
          Charles F. Smith, Site Senior
          Ann Calvaresi-Barr, Evaluator
 
 
 
 
                                         108
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