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States and Providers Adapt to Deliver Home Visiting Services

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Home visiting programs have been around in some form in the US since the 1800s, and the concept itself is timeless. The modern-day form of home visiting that we are familiar with today can be viewed as having begun in the 1970s when the state of Hawaii implemented the Healthy Start Project. Only two years later, the first randomized control trial of a home visiting program, Nurse-Family Partnership, began, initiating the process of building the mountain of evidence we have today that home visiting is good for families.

Today, there are 21 programs that meet the US Department of Health and Human Services criteria for evidence of effectiveness according to the Home Visiting Evidence of Effectiveness project (HomVEE). According to the National Home Visiting Resource Center’s 2019 Home Visiting Yearbook, in 2019 home visiting was implemented in all 50 states. In 2018 a total of 316,850 families received home visiting services from either evidence-based models or those that are considered to be “emerging,” as data is gathered.

However, the spread of COVID-19 and the resulting state isolation orders nationwide introduced new challenges for home visiting programs, at a time when families may strongly benefit from the support these programs provide. In this blog, we discuss the compelling benefits of home-visiting programs and how states and providers have adapted to maintain these services during our current crisis.

Importance and Benefits of Home Visiting
Today, we define a home visiting program as one in which a trained individual, such as a nurse or social worker, conducts in-home visits with a family with a new baby. The point at which visits begin varies by program, with some programs starting visits prenatally to ensure healthy birth outcomes, and others beginning in the first few weeks or months of an infant’s life. Some programs, like Family Connects, are universally available to any family with a new baby; whereas, others have certain eligibility requirements such as income level, or that the mother be a first-time mom. Enrollment in home visiting programs is voluntary.

The proven benefits of home visiting are vast. Beginning with birth outcomes, babies born to families who receive home visits are less likely to be born with a low birthweight. Home visiting is also one of the most compelling interventions to reduce child maltreatment – one analysis looked at a 20-year period in Memphis and found that women receiving home visits were less likely to have their children die from a preventable cause than mothers in the control group. Decreased ER visits, too, are a benefit, with one study finding that children whose families received home visits were 35% less likely to have to visit an ER.

Children whose families receive home visiting services are more likely to enter school prepared to learn, with these benefits extending into more long-term academic outcomes, as measured on standardized tests up to 12 years of age. Home visits also focus on ensuring the family’s economic self-sufficiency, resulting in those families having higher rates of educational attainment and job earnings.  

Adapting to COVID-19
The COVID-19 pandemic has made in-person home visits impossible in most cases. A survey conducted by the Home Visiting Applied Research Collaborative in early April 2020 found that 88% of agencies implementing home visiting were required to stop in-person visits. Survey respondents reported relying equally on video conferencing and telephone (44% each) to conduct visits during the pandemic. The two most commonly reported major challenges to using interactive video conferencing were families not having stable internet access; and families not having tablets, webcams, or computers.

Many states have released guidance on how to successfully conduct a virtual visit. Topics include technical advice on which software is secure enough for use, how best to use a webcam, and how to prepare a family for a virtual visit (one piece of advice is to make sure they have a secure and stable internet connection). Some states address privacy concerns, making sure that virtual home visits are not performed in a manner that an individual who isn’t part of the visit cannot overhear any sensitive information being shared.

There is also helpful information on how best to set up the call, such as how to set the lighting in the room so that the family can see the visitor, as well as establishing a back-up method of communication in case there is a problem with the video conference. Visitors are reminded to be mindful of American Academy of Pediatrics (AAP) guidelines on screen time for children as they develop ways to interact with the child.

Many states also shared information on how to discuss COVID-19 with families, sharing tips on how to keep a calm and healthy perspective so as to minimize anxiety. There are tips, too, on handling children of all ages and their feelings on the pandemic that workers can share with families. Clear medical advice, such as how and when to seek care if experiencing COVID-19 symptoms is also provided for workers to share with families. Visitors are encouraged to only seek and share information from established agencies, such as the CDC.   

Programs may also benefit from information on how to obtain consent required for various program elements, and workers are directed to use electronic tools, such as DocuSign, or send hard copies via the mail service.
In addition, the National Alliance of Home Visiting Models has shared a round-up of program-specific guidance on conducting virtual visits for ten home visiting programs. Healthy Families America, for instance, stresses that workers still treat virtual home visits with the same intentionality as in-person ones. By adhering to the same rules and structure as an in-person visit, a virtual home visit can be just as impactful. Some advice is to keep language consistent, continually referring to the visit as such, and not as a phone call or video call. Visitors are also encouraged to make sure the children are part of the call and to try to keep the focus on the parent-child relationship. Workers are reminded that contact with a caring compassionate visitor is beneficial, whether virtual or in person.

Looking Ahead
Maintaining continuity of visits during the COVID-19 pandemic is important. Research shows that rates of child abuse increase during times of crisis, as stress levels rise and people are unable to access their normal social and support networks. Disturbingly, reports of child abuse have declined during the pandemic, as the individuals normally reporting abuse (teachers, child care providers, etc.) have lost access to these children. In fact, in New York City, reports of child abuse for the first eight weeks of Spring 2020 were down 51% from the levels they were at the same time in 2019. This underscores the critical service that home visiting provides, even as a virtual visit.

The HEROES Act, passed by the House of Representatives in May to continue the federal COVID-19 response, contained language to allow virtual home visits to be considered as home visits through January 2021. It also requested an additional $100 million in supplemental funding for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) to retain staff, engage in additional training on how to conduct virtual visits, and provide more technological resources to families so as to better facilitate home visits. The bill is pending a vote in the Senate.

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