MINNESOTA FAMILY
HOME VISITING NEWSLETTER
A publication from the Minnesota Department of Health Family Home Visiting Program
July 2015 | Volume 3 | Issue 2
GREETINGS FROM THE MINNESOTA
DEPARTMENT OF HEALTH FAMILY HOME
VISITING PROGRAM
Welcome back to the tri-annual Minnesota Family Home
Visiting Newsletter! This is the second edition of the 2015
series, and includes information and resources for a wide
array of home visiting programs across the state.
FEATURED TOPIC:
Evidence Based Home Visiting:
Assessing Need, Capacity, Resources
and Support
There are several questions an agency may ask
in the process of determining readiness to
implement an evidence-based home visiting
model or expand upon an existing model. This
issue of the Minnesota Home Visiting
Newsletter helps address these questions and
offers suggestions for resources and support
throughout different stages of the process.
Contact Us
[email protected]
Subscribe
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Tuesday Topics and the Minnesota Family
Home Visiting Newsletter on the MDH FHV
website.
Readers may recall that the last edition of the newsletter
focused on evidence-based home visiting (EBHV) model
implementation. In particular, that newsletter introduced
the relevance of EBHV, the process of model
implementation and the meaning of model fidelity.
For this newsletter, the authors thought it would be good to
take a step back from the topic of model implementation
and discuss how home visiting agencies can begin to assess
whether or not long-term, EBHV is right for them. What are
the most important questions to ask during this
assessment? What tools and resources are available for
agencies to access? What type of capacity is required of an
agency to implement and sustain an EBHV model? If now is
not the time to implement a model, what options exist for
enhancing your practice? These are all questions that will be
taken into account in this edition.
Whether you are from an agency newly considering an
EBHV model or one interested in expanding an exisiting
model, there is much from which to learn and grow. It may
seem like a daunting process, but as noted in this newsletter
there are many resources out there to help. Implementing a
model is a process that takes time, and summer is a great
time to investigate possibilities. As Charles Bowden once
wrote, “Summertime is always the best of what might be.”
What is best for your community?
MN FHV Newsletter Vol. 3 (2), Page 1
IS EVIDENCE-BASED HOME VISITING RIGHT FOR YOUR AGENCY?
Evidence-based home visiting (EBHV) has been demonstrated to be an effective method of supporting families and
affecting change, particularly those families at highest risk. 1 When exploring the feasibility of implementing an evidencebased home visiting model, there are some key components local public health and tribal nations may wish to consider.
The following offers a brief synopsis of these components.
Conduct a community needs assessment
“When establishing new home visiting programs or expanding existing services using an evidence-based home visiting
model, communities should consider several factors in order to ensure high-quality service delivery that is true to the
intent of those who developed the model and that meets expressed community need.” 2 The ZERO TO THREE Community
Planning Tool (further discussed in the following article) can be used to guide home visiting programs in conducting a
community needs assessment. Part of this process includes reviewing and interpreting data that reflects a particular
community’s needs. The following list includes examples of databases that may be of use:
•
•
•
•
Minnesota Center for Health Statistics
Maternal and child health data
Home visiting program-specific data
Community survey data
Establish program objectives, with clear program goals and expected outcomes
Program goal setting is a local decision and a first step in determining a home visiting approach that best fits the needs of
the local community. Some local agencies focus on a single goal such as preventing low birth weight births, while other
agencies choose to focus on multiple goals, such as promoting a child’s physical health and cognitive development and
preventing child abuse in addition to preventing low birth weight births. The key to keep in mind here is to consider one or
more goals cited above that home visiting can impact.
Minnesota Statute 145A.17 Family Home Visiting Programs Subdivision 1. established the following program goals for the
Minnesota Family Home Visiting Program: foster healthy beginnings; improve pregnancy outcomes; promote school
readiness; prevent child abuse and neglect; reduce juvenile delinquency; promote positive parenting and resiliency in
children; and promote family health and collaboration.
The EBHV program models supported by the Minnesota Department of Health (MDH) Family Home Visiting (FHV)
program have also established goals. These include:
Nurse-Family Partnership (NFP)
Nurse-Family Partnership® (NFP) is an evidence-based, community health program that serves low-income women
pregnant with their first child. Each vulnerable new mom is partnered with a registered nurse early in her pregnancy and
receives ongoing nurse home visits. It is a life-transforming partnership, for the mom and her child. Nurse-Family
Partnership helps families — and the communities they live in — become stronger while saving money for state, local and
federal governments.
1 ZERO TO THREE National Center for Infants, Toddlers and Families, “Supporting Parents and Child Development through Home Visiting.” Retrieved
July 16, 2015 from http://main.zerotothree.org/site/DocServer/HomeVisitssing_Mar5.pdf?docID=7889
2 ZERO TO THREE National Center for Infants, Toddlers and Families, “ ZERO TO THREE Community Planning Tool.” Retrieved June 25, 2015 from:
http://www.zerotothree.org/public-policy/state-community-policy/home-visiting-community-planning-tool-fillable-pdf.pdf
MN FHV Newsletter Vol. 3 (2), Page 2
Program Goals:
1. Improve pregnancy outcomes by helping women engage in good preventive health practices, including
thorough prenatal care from their healthcare providers, improving their diets, and reducing their use of
cigarettes, alcohol and illegal substances.
2. Improve child health and development by helping parents provide responsible and competent care.
3. Improve the economic self-sufficiency of the family by helping parents develop a vision for their own
future, plan future pregnancies, continue their education and find work.
Healthy Families America (HFA)
Healthy Families America (HFA) is a nationally recognized evidence-based home visiting program model designed to
work with overburdened families who are at-risk for adverse childhood experiences, including child maltreatment. It is
the primary home visiting model best equipped to work with families who may have histories of trauma, intimate partner
violence, mental health and/or substance abuse issues. HFA services begin prenatally or right after the birth of a baby and
are offered voluntarily, intensively and over the long-term (3 to 5 years after the birth of the baby).
Program Goals:
1. Build and sustain community partnerships to systematically engage overburdened families in home
visiting services prenatally or at birth.
2. Cultivate and strengthen nurturing parent-child relationships.
3. Promote healthy childhood growth and development.
4. Enhance family functioning by reducing risk and building protective factors.
Family Spirit
Family Spirit Program is an evidence-based and culturally tailored home-visiting intervention delivered by Native
American paraprofessionals as a core strategy to support young Native parents from pregnancy to 3 years post-partum.
Parents gain knowledge and skills to achieve optimum development for their preschool age children across the domains of
physical, cognitive, social-emotional, language learning and self-help. Family Spirit is currently the largest, most rigorous
and only evidence-based home-visiting program ever designed specifically for Native American families.
Program Goals:
1. Increase parenting knowledge and skills.
2. Address maternal psychosocial risks that could interfere with positive child-rearing (drug and alcohol
use; depression; low education and employment; domestic violence problems).
3. Promote optimal physical, cognitive, social/emotional development for children from ages 0-3.
4. Prepare children for early school success.
5. Ensure children get recommended well-child visits and health care.
6. Link families to community services that address specific needs.
7. Promote parents’ and children’s life skills and behavioral outcomes across the lifespan.
Minnesota Statute 145A.17 Family Home Visiting Programs Subdivision 1. additionally established the following expected
outcomes to be measured for the Minnesota Family Home Visiting Program:
• Appropriate utilization of preventive health care;
• Rates of substantiated child abuse and neglect;
• Rates of unintentional child injuries;
• Rates of children who are screened and who pass early childhood screening;
• Rates of children accessing early care and educational services;
• Program retention rates;
• Number of home visits provided compared to the number of home visits planned; and
• Participant satisfaction; and rates of at-risk populations reached.
Local decision makers and funders should consider program expected and realized outcomes for families to determine
impacts on families, the community, etc., as well as cost effectiveness of home visiting services provided.
MN FHV Newsletter Vol. 3 (2), Page 3
Define the target population to be served to ensure that families with greatest need have access to
services
Minnesota Statute 145A.17 has identified certain family characteristics for local home visiting programs to consider when
defining their target population including:
• Adolescent parents;
• A history of child abuse;
• Domestic abuse or other types of violence;
• A history of domestic e abuse, rape or other forms of victimization;
• Reduced cognitive functioning;
• A lack of knowledge of child growth and development stages;
• Low resilience to adversities and environmental stresses;
• Insufficient financial resources to meet family needs;
• A history of homelessness; and
• A risk of long-term welfare dependence or family instability due to employment barriers.
The EBHV program models also have specific family risk criteria that determine eligibility for program model enrollment.
For more information on target population perimeters, contact a nurse or model consultant from the MDH FHV program.
Evidence-based home visiting (EBHV) has been demonstrated to be an effective method of
supporting families and affecting change, particularly those families at highest risk.
– ZERO TO THREE
Determine staff capacity; assess skills and characteristics of your staff that are best suited to provide
home visiting services to achieve program objectives
Home visiting programs that are most successful, have home visiting staff that are capable and supported in developing
therapeutic, long term relationships with families. Depending on program criteria, local agencies hire professional home
visiting staff including bachelor degree prepared nurses, early childhood educators or licensed social workers to provide
direct home visiting services to families and supervisory support to home visiting staff. Paraprofessionals may also be
considered to provide direct services to families, when serving a diverse community. Paraprofessionals are most effective
when supported with ongoing in-service training and close supervision by professional staff. Examples of personal
qualities desired in home visitors of any discipline include:
• Active listener;
• Non-judgmental;
• Empathetic;
• Possess reflective capacity; and
• Uses a non-directive approach.
Home visitors with limited caseloads (no more than 25 families per 1.0 full-time employee and no more than 12 families
for a half-time employee), and who receive regular and ongoing feedback/supervision, are better able to meet the diverse
needs of clients.
In determining the staffing capacity an agency needs to successfully provide home visiting services, it is important to ask
questions such as:
• In addition to the above list, what qualities does your agency most value in an employee?
• Does the home visiting program have buy-in from its staff? …from the community?
• What challenges might staff encounter while conducting a home visit that may require support either from a peer,
a supervisor or overall program infrastructure?
MN FHV Newsletter Vol. 3 (2), Page 4
Plan and train staff within a structure that integrates concepts that services are voluntary, beginning
early during the prenatal period or very early postpartum, services are intensive over a long period of
time; services are family focused, strengths based and respect family diversity
For agencies that are considering implementing an EBHV model, home visitors and supervisors will be required to attend
core home visitor training before providing services to families. Core model training includes a combination of distance
learning, on-line learning modules as well as face to face training on model elements and evidence-based curriculum. In
addition to training offered by the evidence-based models, the MDH FHV program offers a variety of training and
professional development options that enhance learning and build capacity for all home visitors and supervisors
regardless of model. For more information about training opportunities offered by the MDH FHV program, visit the MDH
FHV Training and Professional Development webpage.
All home visiting services require well-trained staff that offer voluntary services. Some families may not expect
governmental assistance in childrearing and some families may actively oppose it. If home visiting is offered voluntarily,
families may well begin to think of their home visitor as their partner and helpful supporter and be more receptive to
services that are offered.
Optimally home visiting services begin during the prenatal period. Interventions that are offered frequently (every week
or every other week) and occur over a long period of time (ideally until the child is 2 years old) have more significant and
sustained effects and achieve the identified program outcomes.
Effective home visiting programs respond to the unique needs of each individual family, build on family strengths and
work to build the capacity and self-sufficiency of families they serve. Quality programs recognize and appreciate the
cultural bases of parenting and avoid stereotyping. Families are more likely to engage in services that are culturally and
linguistically appropriate. In addition, a study conducted by the Pew Home Visiting Campaign, family retention in an
EBHV program was believed to be related to, “the number of planned visits, the duration of visits, persistence on the part
of the home visiting team, the use of a team to prevent staff burnout over individual, hard-to-reach families, and a weekly
group supervision meeting to troubleshoot issues that came up.” 3
Overall, when considering engaging community partners, families or others it is important to think of the message that
you would like to share about home visiting and its outcomes. Research done by Positive Opinion Strategies and The
Mellman Group and shared at the Fifth National Summit on Quality in Home Visiting Programs (May 7-8,2015; see the
presentation, “Morning Plenary: Language to Engage Families,” on the Home Visiting Summit webpage) provided
findings of language that resonates with families and others. Home visiting agencies may consider incorporating some of
those findings in public relations materials that are developed for their programs.
Identify agency partners and referral linkages in the community
Effective home visiting programs collaborate and coordinate with other community services to ensure that families are
receiving all the services they need. Connecting families with other child and family services in communities will help to
ensure that young children and parents have the comprehensive support they need. In instances when parents and
children have needs beyond those addressed by the home visiting program in which they are enrolled, they should be
linked to additional resources available in their community , such as high–quality child care programs and comprehensive
early childhood programs such as Early Head Start, early intervention programs, health assistance programs and mental
health services. 4
Building community partnerships is an expectation for implementation of an EBHV model. The need for referrals, client
services and ongoing program supports are vital to the success of model implementation. Local home visiting agencies are
encouraged to devote energy and human resources to building and maintaining community partnerships and develop new
or have in place existing community advisory boards. Advisory boards should have diverse representation of local
community partners to ensure broad-based community support for implementation of the home visiting program model.
Consider working with partners to determine community need, capacity gaps, program supports and sustainability. (See
the following articles for more information on the value of building partnerships.)
Radcliffe, J. (November 2012). Predictors of Maternal Involvement in the MOM Program Randomized Controlled Home Visiting Program:
Demographic and Program Implementation Factors, http://www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2013/MOM
Programreportpdf.pdf
4 Op. cit.
3
MN FHV Newsletter Vol. 3 (2), Page 5
Establish data system support for program evaluation for home visitors to report program process and
outcome data and for ongoing quality improvement efforts
Data collection, reporting, analysis and evaluation is a critical component and expectation of all local public health and
tribal home visiting in Minnesota as well as the EBHV models. There are a variety of data systems available to local home
visiting programs to collect and report critical home visiting data elements to MDH, including:
•
•
•
•
Carefacts
Nightingale Notes (CHAMP)
Nurse-Family Partnership's ETO
PH-Doc (Xerox); no website, contact [email protected]
Effective home visiting programs use data to determine if the program is being implemented as designed, to the extent to
which goals and objectives are being met and to determine areas where program implementation may need improvement.
Local agencies should identify staff and allocate staff time (portion of a full-time equivalent) to enter and report home
visiting data to MDH and/or the EBHV model. Local agencies should also identify staff that will be responsible for looking
at the home visiting program data for ongoing quality assurance and improvement efforts.
Identify funding sources to provide long-term program sustainability
Local public health and tribal nations in Minnesota have a variety of funding streams to consider to support home visiting
services and the implementation of an EBHV model, including:
• TANF;
• MCH Block Grant;
• Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) I (Formula);
• MIECHV II (Expansion);
• Local Tax Levy;
• Local Public Health grants;
• Medical Assistance;
• MN Care;
• PMAP;
• Private Health Insurance; and
• Other grants.
The estimated cost for sustaining an EBHV model can range anywhere from $2,000 - $13,000 per family served per year 5
(the average cost in Minnesota is $7,800 per family per year), with staff salaries making up the primary cost.
Local agencies choose to invest in long term, EBHV because it is a wise investment that can yield substantial, quantifiable
and long term benefits to the parents, children and communities in which they live. Agencies that consider implementing
an EBHV model will be asked by model developers to describe how the agency has secured political and advocacy
commitments to sustain the program. The agency will be required to identify local decision makers, funders and program
champions that will support model implementation and if funding is cut or local leadership changes, to think about
partners that would advocate sustaining the model program. Letters of support from local partners and advocates will be
required by model developers before implementing an EBHV model.
Conduct continuous quality improvement activities
A key component in advancing a home visiting practice is utilizing continuous quality improvement (CQI). The goal of
CQI is to examine home visiting practices to improve services to families. Quality improvement is “the use of a deliberate
and defined improvement process and the continuous and ongoing effort to achieve measurable improvements.” 6
CQI is imbedded in all of the EBHV models currently supported by MDH (Family Spirit, HFA and NFP). Funding from
the MIECHV Program further supports the use of CQI in implementation of the models. MDH convenes a quarterly CQI
Learning Collaborative comprised of Minnesota’s MIECHV-funded home visiting teams (home visitors and supervisors).
5 Mathematica Policy Research (January 2014). Costs of Early Childhood Home Visiting: An Analysis of Programs Implemented in the Supporting
Evidence - Based Home Visiting to Prevent Child Maltreatment Initiative.
6 MDH Office of Performance Improvement staff, adapted from the Public Health Accreditation Board (PHAB), Glossary of Terms Version 1.0
MN FHV Newsletter Vol. 3 (2), Page 6
Goals include the promotion of practicing CQI skills and sharing small changes of improvement in home visiting practice.
For more information about the CQI Learning Collaborative and other CQI resources, contact the MDH FHV program.
PLANNING FOR HOME VISITING IN YOUR COMMUNITY
The ancient African proverb states, “It takes a village to raise a child.” Perhaps used to the point of cliché, we may forget
that there is a lot of wisdom in this very old saying. This principle also applies to those services that support parents in
raising children, such as family home visiting. The most successful programs do not operate in a vacuum, but instead rely
on a community that understands and supports its goals and mission. Research shows that family home visiting services
are most successful recruiting and engaging families when these specific components are included:
•
•
•
•
•
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A community that is part of planning, understands the program and supports its development (see links to the
“Advancing Health Equity Legislative Report” and “Adverse Childhood Experiences in Minnesota” in the
Resources section below for background information for planning and understanding community needs);
Program staff that are well-trained and supported through high-quality supervision;
Strong administrative support;
Ongoing evaluation of program implementation so that quality issues can be addressed in a timely manner;
An environment where the need for the program is clearly understood and there is no duplication of efforts spirit
of collaboration with other early childhood programs; and
Strong local leadership to nurture the development of the services. 7
Early childhood home visiting is a proven strategy for at-risk families. But how do you know if your community is ready to
support or expand an evidence-based program? According to the ZERO to THREE Policy Center, careful and thorough
assessment of your community can assure inclusion of stakeholders and give direction to your planning process. 8 A needs
assessment is a required process by the current, federal Maternal, Infant and Early Childhood Home Visiting (MIECHV)
funding to assure programs are meeting the needs of their target population. Required components of the assessment
include:
• The data that identifies your community as at-risk (includes community needs and strengths);
• The quality and capacity of exisiting programs for early childhood home visiting (identifying gaps); and
• Connection with other assessments, such as planning for the Head Start Act or MCH Block Grant.
ZERO TO THREE provides one such planning tool that can used by communities. This tool, which is considered quite
thorough, stresses that the first step is including all of the community’s stakeholders in family home visiting. Only
through utilizing a comprehensive and inclusive approach can a true picture of community needs develop. This approach
also helps to engage the entire community that will support family home visiting through referrals and adjunctive services.
Such buy-in is vital for the success of a family home visiting program and will open the door for communication across all
entities that may provide various services to the same families. Families benefit when silos become bridges.
Harris, E. (Spring 2010). Six steps to successfully scale impact in the nonprofit sector. The Evaluation Exchange - Harvard Family Research Project,
XV(1), www.hfrp.org
8 ZERO TO THREE National Center for Infants, Toddlers and Families, “ ZERO TO THREE Community Planning Tool.” Retrieved June 25, 2015 from:
http://www.zerotothree.org/public-policy/state-community-policy/home-visiting-community-planning-tool-fillable-pdf.pdf
7
MN FHV Newsletter Vol. 3 (2), Page 7
The other advantage of utilizing a tool can be to help communities gather information about which evidence-based family
home visiting model would be the best fit. A comprehensive assessment will reveal answers to these key considerations
when choosing a home visiting model:
•
•
•
•
•
•
The model’s goals match the community’s goals and needs;
The community has the resources available to maintain fidelity to a model (community resources to implement
the model’s program standards and carry out goals);
Internal resources exist for billing and data collection as well as technology needs;
Staffing needs can be met through the pool of qualified applicants (some models require baccalaureate-prepared
nurses while others may employ paraprofessionals or others);
Other services exist that can support the goals of family home visiting and serve families such as medical and
mental health and social services; and
The cost per family of the program can be sustainable. 9
Tools, such as the ZERO TO THREE Home Visiting Community Planning Tool, require time and data to complete, and
communities may not be able to address all of the components at one time. However, they can be used as a guide to help
you through the planning process and take a snapshot of the unique needs of your community. In this way, you will gain a
deep understanding of what it takes to raise a child in your village and just what your village is.
ASSESSING YOUR AGENCY’S CAPACITY TO IMPLEMENT EVIDENCE-BASED HOME VISITING
Based on an in-depth literature review of over 2,000 articles on the topic of program implementation, the National
Implementation Research Network determined that, in general, there are five main stages of implementation success.
These include: 1) exploration; 2) installation; 3) initial implementation; 4) full implementation; and 5) program
sustainability. 10 A site just beginning to consider evidence-based home visiting (EBHV) is in the exploration stage, and is
likely asking questions and accessing resources such as those sited in the above articles around forming
partnerships/teams, conducting a community needs assessment and identifying the structural components (i.e. financial,
staffing, administrative, etc.) required to implement.
Building upon the exploration stage, the installation stage is one of development. In this stage, factors to consider include:
•
•
•
•
•
•
•
•
•
Who are the stakeholders? Who will be your champion and who will need to be influenced? How will stakeholders
be engaged?
Engaging elders, community groups and programs who have been successful with or may have a deeper
knowledge of your target families.
What are your assets and gaps?
Who will refer at risk families to your program?
Comparing model program policies and procedures with your current policy and procedures.
 Are there policies and procedures in place that will support engaging and retaining at risk communities?
A plan for recruiting, hiring and retaining appropriate staff who have reflective capacity
A plan for ensuring clinical and reflective supervision
Identifying staff training needs; providing/accessing any applicable training;
Building program, community and system supports that encourage EBHV practice.
Both the exploration and the installation stages comprise what Mathematica Policy Research terms as the foundation
area of infrastructure capacity. 11 In other words, a site’s capacity to successfully implement evidence-based home visiting
relies on a firm foundation rooted in planning and collaboration activities that encourage systems change. This, in turn,
leads to an infrastructure that supports EBHV implementation, growth and ultimate sustainability of the program. 12
Ibid.
National Implementation Research Network (NIRN), http://nirn.fpg.unc.edu
11 Boller, K., Daro, D., Del Grosso, P., Cole, R., Paulsell, D., Hart, B., Coffee-Borden, B., Strong, D., Zaveri, H. & Hargreaves, M. “Making Replication
Work: Building Infrastructure to Implement, Scale-up, and Sustain Evidence-Based Early Childhood Home Visiting Programs with Fidelity.” Children’s
Bureau, Administration for Children and Families, U.S. Department of Health and Human Services. June 2014.
12 Ibid.
9
10
MN FHV Newsletter Vol. 3 (2), Page 8
Systems change can be a daunting process to begin. There are several layers to consider including how various systems,
such as public health, child welfare and medical providers, are connected, as well as how a given system functions from
day-to-day. 13 A formal system traditionally has a hierarchy in place that dictates program development and
implementation, 14 and often focuses on addressing an immediate problem in the community. To better align with the
principles of EBHV, using a strengths-based approach to program planning and implementation is encouraged. Following
a strengths-based approach is less focused on solving a specific problem and more focused on a unified vision for the
community’s future. 15 In this approach, taking into account all of the systems in place – service providers, government
interests and stakeholders – and including community members themselves in the process is key to forming a unified
vision for systems to operate in, grow and improve.
The ZERO TO THREE Home Visiting Community Planning Tool 16 referenced above was designed to help sites think
through the various components of the foundation area of infrastructure capacity, and begin to identify areas where
infrastructure is already in place and others where action steps can be taken to move a site toward the installation and
implementation stages of EBHV. In using this tool or others like it, the steps to take in influencing systems change become
more obvious and are framed in a more manageable, user-friendly way.
As a site moves through the various stages of program implementation, it is important to keep in mind that these stages
are not always linear. In fact, “implementation is not an event, but a process, involving multiple decisions, actions, and
corrections to change the structures and conditions through which organizations and systems support and promote new
program models, innovations, and initiatives. Implementing a well-constructed, well-defined, well-researched program to
the point of successful functioning and sustainability can be expected to take two to four years.” 17
In addition to the above, it is helpful to keep in mind that, “home visiting services are most successful when key
components are integrated. These include the following:
• A community that understands the program and supports its development;
• Program staff that are well-trained and supported through high-quality supervision;
• Strong administrative support;
• Ongoing evaluation of program implementation so that quality issues can be addressed in a timely manner;
• An environment where the need for the program is clearly understood and there is no duplication of efforts;
• A spirit of collaboration with other early childhood programs; and
• Strong local leadership to nurture the development of the services.” 18
FOLLOWING AN EVIDENCE-BASED PRACTICE
The American Nurses Association, Scope and Standards for Public Health Nurses 19 defines evidence-based practice as, “an
approach to public health care practice in which the public health nurse is aware of evidence in support of his or her
clinical practice, and the strength of that evidence. Evidence-based practice in home visiting translates into combining a
home visitor’s work experience; including his/her knowledge of a particular client’s situation (e.g., cultural values,
household dynamics, substance use disorders, etc.) with what basic science and patient-centered research has
demonstrated as safe, accurate, and effective. There are many evidenced-based practices embedded within an evidencebased home visiting (EBHV) model. However, local programs not implementing an EBHV program can still incorporate
many evidence-based practices to enhance the quality of services they are delivering.
13 Kendrick, M., Jones, D., Bezanson, L. & Petty, R. “Key Components of Systems Change,” Independent Living Research Utilization Community Living
Partnership. January 2006.
14 Ibid.
15 Hammond, W. “Principles of Strengths-Based Practice,” Resiliency Initiatives. 2010.
16 ZERO TO THREE National Center for Infants, Toddlers and Families, “ ZERO TO THREE Community Planning Tool.” Retrieved June 25, 2015 from:
http://www.zerotothree.org/public-policy/state-community-policy/home-visiting-community-planning-tool-fillable-pdf.pdf
17 Metz, A., Naoom, S.F., Halle, T. & Bartley, L. “An Integrated Stage-Based Framework for Implementation of Early Childhood Programs and Systems
(OPRE Research Brief OPRE 201548),” Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S.
Department of Health and Human Services. 2015.
18 Op. cit.
19 American Nurses Association (2013). Public health nursing (2nd ed.). Silver Spring, MD.
MN FHV Newsletter Vol. 3 (2), Page 9
Evidence-based practice in home visiting translates into combining a home visitor’s work
experience; including his/her knowledge of a particular client’s situation (e.g., cultural values,
household dynamics, substance use disorders, etc.) with what basic science and patient-centered
research has demonstrated as safe, accurate, and effective.
Evidence-based practice in home visiting
There are several elements of home visiting programs that have been identified within research as effective and can
enhance the quality and impact of family home visiting programs that don’t use an EBHV model. These factors are:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Voluntary: Parents who are voluntarily involved are more receptive to services
Family-focused and Strengths Based: Effective programs respond to the unique needs of each individual
family, build on family strengths and work to empower parents.
Respect for diversity: Families are more likely to engage in services that are culturally and linguistically
appropriate. Effective programs value diversity.
Connection to other community services: Effective programs collaborate and coordinate with other
community services to ensure that families are receiving all the services they need.
Targeted: Scarce resources are most effectively utilized when services are targeted to those families with the
greatest need.
Begin Early: Effective programs begin services as early as possible, optimally prenatally.
Intensive: Interventions that are frequent and occur over a long period of time have more significant and
sustained effects.
Long term: Optimally, services continue until the child is at least 2 years old.
Promote preventative health care: Effective programs support and encourage families to utilize preventative
health care and connect with a primary care provider.
Promote delay of subsequent pregnancies: Effective programs support and encourage participants to delay
subsequent pregnancies when appropriate.
Limited caseloads: Home visitors with limited caseloads are better able to meet the needs of their clients.
Caseload limitations will vary with program purpose and focus.
Carefully recruited and well-trained staff: Effective programs employ well-trained staff. Program staff is
selected based on their education, work, and life experiences, as well as their ability to communicate and establish
trusting relationships.
Ongoing supervision: Effective programs provide staff with continuous, high quality supervision.
Theory-driven: Effective programs are based on strong scientific theory and target relevant risk and protective
factors that have been shown to impact the healthy development of young children.
Clearly defined goals and objectives which home visitors know how to reach: Effective programs have
goals which meet the needs of the families served and influence what home visitors do in the home. Goals also
guide the type of training and ongoing supervision home visitors receive. Understanding goals and objectives
helps home visitors plan activities for visits and tells families what they may gain from participating in the
program.
Evaluation and Continuous Quality Improvement: Effective programs determine evaluation and QI
processes early and use data to determine if programs are being implemented as designed, extent to which goals
and objectives are being met and area which may need refinement.
In addition to moving towards some of the elements of effective family home visiting programs, there are other ways that
local programs can incorporate evidence-based practices into their programs. One example is implementing an evidencebased parenting curriculum such as Growing Great Kids (GGK) or Partners in Parenting Education (PIPE) to promote the
parent-child relationship. Using an evidence-based screening tool to screen for domestic violence (HARK), depression
(PHQ-9 or Edinburgh Postnatal Depression Screen), parent-child relationship (NCAST) and child development (ASQ and
ASQ SE) are other ways to incorporate evidenced-based practice into your home visiting program. For more information
MN FHV Newsletter Vol. 3 (2), Page 10
on screening tools, see the following pages on the Minnesota Department of Health’s (MDH) Family Home Visiting (FHV)
website:
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Information for Home Visitors and Supervisors
Information for Tribal Governments
MDH support for non-models interested in using evidence-based practices
The MDH FHV program offers support in many different ways for programs looking to add or enhance their practice
within home visiting. The first place to start would be to have conversation with your FHV Nurse Consultant. They will be
able to help you assess your current practice and work with you to incorporate other evidence-based practices into your
home visiting program. This may include incorporating evidenced-based screening tools into your practice or adopting an
evidence-based parenting curriculum. MDH also offers a variety training that promotes evidence-based practice. Growing
Great Kids and Partners in Parenting Education are offered on a regular basis. MDH also provides training on using the
NCAST parent-child relationship assessment, ASQ and ASQ-SE and an evidence-informed intervention around domestic
violence screening, called Futures without Violence. For more information on the trainings offered by MDH, please visit
the MDH FHV website.
SPOTLIGHT: PREPARING FOR AND CHOOSING A HOME VISITING PROGRAM THAT FITS
YOUR COMMUNITY
Cook County Maternal Child Health Home Visiting Program
By Allison Heeren, BScN, PHN at Cook County Public Health and Human Services
How do we as health care providers measure infant and maternal risk? On referral forms for home visiting, risk is
indicated by check boxes for reasons such as delivery complications, feeding status, maternal age and weight, socio
economic and educational status, substance use, mental health status, number of previous children and parental
relationship. There is no question that all of these are important when assessing the potential needs of a family with a
newborn.
But what about the risks that go beyond “classic”? Things like, geographic isolation, no running water, only woodstove
heat, homes 40 miles from the closest town center and medical care and living a two-hour drive from the delivering
hospital. None of these indicate inherent risk by themselves, but they do add complexity and may contribute to further
vulnerabilities for even the most functional caregivers. These circumstances represent lifestyles chosen by some families
living in Cook County.
Cook County is beautiful and dramatic with wild forest, the great Lake Superior and borders reaching up to Canada. It as
large in land area as it is small in population. There are approximately 5,500 full-time residents, with 30-45 births
registered to the county each year. These numbers are few, but the risks for caregivers and babies are both classic and
MN FHV Newsletter Vol. 3 (2), Page 11
unique. Knowing this, it has been at the core of Cook County Maternal Child Health Home Visiting Program, to serve all
families. The belief is that all families welcoming a newborn home need support - some more, some less - and services
should be offered accordingly.
It is because of this population health approach that Cook County has historically sought funding that allows for
continuance of this mission. Fortunately, the Arrowhead Health Alliance Grant as the primary backing for last six years
has provided just that. With anticipation that this grant was terminating in April of 2015, preparation began a year prior to
evaluate both the actual value of the Universal Home Visiting program itself, and plan for the means to be able to sustain
it. With no state or federal funds accessible for a non-targeted home visiting programming, it became evident that the
stakeholders for the program would be the people of the community, and specifically the county board of commissioners.
In order to justify asking for this financial support, there had to be evidence of value.
A survey was developed and sent from the county Public Health Department to all families from the past two years that
had participated in the Cook County Universal Home Visiting program. The survey was anonymous in nature to allow for
the most honest feedback. The significant return rate of the survey, the overwhelmingly general positive response, and the
sharing of personal stories from past clients on how Universal Home Visiting Program supported them was instrumental
in the approval from the Cook County Commissioners in allowing for county funding to support the service. Once funding
was stabilized, the maternal child health team’s mission was to find an evidence based program for Universal Home
Visiting that would be: realistic for rural health departments and would also allow for outcomes that would then be
available to show accountability to the stakeholders investment and thus ensure sustainability of programming.
Family Connects Universal Home Visiting program, rooted in research by Duke University and Durham, N.C. Public
Health Department, aligns with Cook County Public Health’s vision of serving all families without flaw. With published
evidence of the program showing decrease use of emergency room care, reduction of maltreatment and improved
connectedness to community resources for families, Cook County began pursuing implementation of the program. The
relationship with Family Connect fellows started with an email from Cook County reaching out with hopes that this
prestigious group may feel they were as good of a fit with us as we thought them. Through conversation they have come to
understand the uniqueness of Cook County rural location, demographics, and limited resources and maintain that Cook
County is able to attain model fidelity. With this combined goal, and with the significant cost of implementing an evidence
based program, financial considerations began. Grant applications were written and approved from health plans, local
foundations, and health boards. Cook County is now able to move forward with finalizing plans for implementation of the
Family Connect Program this fall.
The process of evaluating the past and current home visiting program as well as determining the future direction and
model adoption in Cook County has been successful because of strong communication. It is to be clear, direct and often.
For it is with all partners believing in the benefit of supporting all caregivers that Universal Home Visiting programming
continues to be a core population public health service in Cook County. Working with and alongside the families, meeting
with local community and state organizations, schools and medical providers, talking with human services and by
educating commissioners and grantees allows for strength in common goals.
While Cook County is abundant with natural resources, the strongest resource is the people and partnerships across
disciplines that provide services all families in whatever way “risk” is to be defined.
For more information on Cook County’s community evaluation process, survey development, Family Connect model
selection and partnering in the adoption of Family Connect, please contact Cook County Public Health and Human
Services at 218.387.3620.
RESOURCES
In addition to the resources referenced throughout the above articles, the following offers a glimpse of evidence-based
implementation information available online:
• Advancing Health Equity Legislative Report (Minnesota Department of Health, 2014)
• Adverse Childhood Experiences in Minnesota (Minnesota Department of Health)
• Evidence on Home Visiting and Suggestions for Implementing EBHV Through MIECHV (M. Rebecca Kilburn, 2014)
• Family Spirit Program
• Healthy Families America
MN FHV Newsletter Vol. 3 (2), Page 12
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Nurse Family Partnership National Service Office
Public Health Foundation Teams Toolbox
Recruitment and Retention of Home Visiting Staff (Maternal, Infant and Early Childhood Home Visiting Technical
Assistance Coordinating Center, March 2015; audio version available at ZERO TO THREE)
A Road Map to Implementing Evidence-Based Programs (SAMHSA’s National Registry of Evidence-Based Programs
and Practices, June 2012)
Supporting Evidence Based Home Visiting (U.S. Department of Health and Human Services, Administration for
Children and Families, Children's Bureau)
MN FHV Newsletter Vol. 3 (2), Page 13