Texas Home Visiting Program Implementation and Operations Guide

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Texas Home Visiting Program

Implementation and Operations

Guide

Office of Health Coordination and Consumer Services

www.TexasHomeVisiting.org

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June 8, 2015 Office of Health Coordination and Consumer Services Page 1 www.TexasHomeVisiting.org

Table of Contents

... 1

Executive Summary

... 2

Chapter 1 Overview of the Texas Home Visiting Program

... 3

Chapter 2 Quick Start Guide

... 7

Chapter 3 Direct Service Delivery

... 11

Chapter 4 Data Collection

... 19

Chapter 5 Implementing System-Level Strategies

... 23

Chapter 6 Sustainability

... 27

Chapter 7 Evaluation

... 29

Chapter 8 Lessons Learned

... 33

Appendix A

... 35

Who to Call:

... 37

Appendix B

... 39

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Page 2 Office of Health Coordination and Consumer Services June 8, 2015 www.TexasHomeVisiting.org

Executive Summary

The purpose of the Implementation and Operations Guide is to provide direction and best practices for implementing new home visiting programs in Texas. The information presented comes from the Texas Health and Human Services

Commission (HHSC), which oversees and manages the Texas Home Visiting Program (THV), and from the Child and Family Research Partnership (CFRP) at the University of Texas at Austin, which evaluates the implementation and outcomes of THV and conducts the federally-mandated evaluation components.

The guide is intended to benefit any new THV implementation effort, regardless of funding stream (i.e., federal or state). The first chapter of the guide is an overview of THV followed by a quick start guide in Chapter 2, which provides an overview of the elements that are required for implementation. Chapter 3 focuses on implementing home visiting programs and Chapter 4 highlights the importance of accurate data collection. Chapter 5 details the systems-level work and provides guidance on coalition building and community-level data collection. Chapter 6 provides information on how to leverage state and federal funds to sustain both the direct service and systems-level work. Chapter 7 presents the required evaluation components. Finally, Chapter 8 provides important lessons learned from the previous implementation efforts.

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Chapter 1

Overview of the Texas Home Visiting Program

Purpose

The purpose of the Texas Home Visiting Program (THV) is to improve child and family well-being in at-risk communities by providing families with young children home visiting services and by developing early childhood coalitions to both integrate services and enhance systems within a community.

Home Visiting in Texas

HHSC defines home visiting programs as voluntary-enrollment programs, with home visiting as the primary service delivery strategy. Trained early childhood or health professionals (i.e., nurses) or paraprofessionals regularly visit the homes of pregnant women or families with children under the age of six who are at risk for negative outcomes around maternal and/or child health and school readiness and achievement.

In Texas, home visiting programs are funded at the federal, state, and local levels and include program models that are evidence-based (meets the U.S. Department of Health and Human Services’ (DHHS) criteria for demonstrated

effectiveness) and those that are promising practices (have some, but not sufficient evidence of demonstrated effectiveness). The home visiting programs operating in Texas along with whether they meet the federal criteria for evidence-based are presented in Table 1.

Table 1. Home Visiting Program Models Operating in Texas

Home Visiting Program Meets federal criteria for

evidence-based

AVANCE Parent-Child Education Program N/A

Early Head Start (EHS home-based) YES

Exchange Parent Aide N/A

Family Connections No

Healthy Families America (HFA) YES

Healthy Start No

Home Instruction for Parents of Preschool Youngsters (HIPPY) YES

Incredible Years N/A

Nurse-Family Partnership (NFP) YES

Nurturing Parenting Program (NPP) No

Parents and Children Together (PACT) N/A

Parents as Teachers (PAT) YES

Positive Parenting Program (Triple P) No

SafeCare N/A

Systematic Training for Effective Parenting (STEP) N/A

Note: Bold italics represent program models included in THV; N/A indicates the model has not been evaluated for effectiveness based on federal criteria

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The Office of Health Coordination and Consumer Services (OHCCS) within HHSC oversees and manages THV, which is funded through a mix of funding sources (Figure 1).

Figure 1. Federally- and State-funded Home Visiting Programs in Texas

•

Improved pregnancy outcomes

•

Improved maternal or child health outcomes

•

Improved cognitive, social and emotional development of children

•

Increased school readiness of children

•

Reduced child abuse, neglect and injury

•

Improved child safety

•

Improved parenting skills, including nurturing and bonding

•

Improved family economic self-sufficiency

•

Reduce crime, including domestic violence

•

Improve the coordination and referrals for other community resources and supports

Texas Home Visiting Program Goals*

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THV Communities

THV operates across the state in communities that have been identified through a comprehensive needs assessment. Needs assessment data included community-levels of poverty (both overall and specifically for children), rates of preterm and low birth weight babies, incidence of child maltreatment and other family violence, among others. As of March 2015, the counties in which THV is currently operating include:

 Anderson  Bexar  Cameron  Cherokee  Dallas  Ector  Gregg  Hidalgo  Midland  Nueces  Potter  Randall  San Patricio  Willacy  Wichita  Rusk  Panola  Harrison  Upshur  *Collins  *Starr  Lamb  Hale  Floyd  Hockley  Lubbock  Crosby  Terry  Lynn  Garza  El Paso  Tarrant  Williamson  Travis  Webb  Fort Bend  Harris  Chambers  Jefferson  Orange  Hardin  *Montgomery  *Hays

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Chapter 2

Quick Start Guide

Required Elements

This chapter provides grantees (e.g., community leads) with an overview of the required elements for any new THV implementation effort. The two overarching required elements in THV are: 1) direct service delivery—providing home visiting services to families, and 2) implementing system-level strategies to address community issues impacting young children. Guidance on sustainability efforts and participation in evaluation activities is presented separately. More detailed information on each element is provided in the subsequent chapters.

Direct Service Delivery

Providing home visiting services to families in THV includes implementing home visiting program models, collecting accurate data, using that data in decision-making and for continuous quality improvement initiatives, and participating in required training and evaluation activities.

Implementing Home Visiting Programs

Grantees must choose at least one of the following four program model(s) to implement:



Early Head Start – Home Based (EHS-HB)



Home Instruction for Parents of Preschool Youngsters (HIPPY)



Nurse Family Partnership (NFP)



Parents as Teachers (PAT)

Grantees can decide to implement a program model that is new to their community or expand an existing home visiting program. Grantees may choose to subcontract the direct service delivery to another organization in the community. Additional detail about implementing home visiting programs is provided in Chapter 3.

Continuous Quality Improvement

Continuous quality improvement (CQI) is a systematic cycle of assessment, analysis and improvement activities performed by home visiting programs that focus on improving program performance while maintaining fidelity to the evidence-based program models. Guidelines for grantees on developing CQI teams and process improvement activities are outlined in Chapter 3.

Data

Accurate data collection is essential for making informed programmatic decisions, continuous quality improvement, and for both federal- and state-mandated performance measures when implementing home visiting programs. The importance of accurate data collection and how grantees can best use their data are outlined further in Chapter 4.

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System-Level Strategies

In addition to providing families with home visiting services, grantees, with the exception of the GR-funded Texas Nurse Family Partnership Program, must implement system-level strategies that address broad policy, practice, or community infrastructure issues that impact young children and families and benefit the community at-large. This systems work is presented in greater detail in Chapter 5, and consists of four interrelated elements: developing or enhancing a local early childhood coalition, collecting community-wide data around child health and well-being, implementing activities to

coordinate cross-sector services and address broader community-level issues, and working to increase community investment and ownership to ensure strategic growth and sustainability.

Sustainability

Grantees must develop a strategy and foundation for long-term sustainability for both the direct service delivery and the systems work. This will include developing and implementing local sustainability plans to effectively leverage state and federal funds. HHSC will work with grantees to identify realistic goals to assist in growing programs to scale. Additional detail on effectively leveraging state and federal funds is provided in Chapter 6.

Evaluation Activities

All grantees (with the exception of the GR-funded Texas Nurse Family Partnership program) implementing home visiting programs as a part of THV, regardless of funding source, are required to participate in a program implementation evaluation (PIE) that is being conducted by CFRP at the University of Texas at Austin. PIE examines the factors that enhance and interfere with the successful implementation of home visiting programs across the state. Participation in additional evaluation activities is required for MIECHV-funded programs. The evaluation activities are described in

Chapter 7.

Essential Roles and Responsibilities for Implementation

To successfully implement home visiting programs and system-level strategies that benefit the community at-large, there are various roles for which responsibility must be assumed. The specific staffing structure is up to the discretion of the grantee, but the needed roles are outlined below in Table 2 along with examples of staffing structures from previous implementation efforts in Texas.

Table 2. Essential Roles and Responsibilities for Implementation

Element Essential Roles and Responsibilities Direct Service

Delivery

Oversight of home visiting activities, home visitors, and accurate data reporting Delivery of home visiting services to clients in their home

Data reporting and quality assurance, CQI, training, communication System-Level

Strategies

Oversight of functions related to coalition building and systems work Oversight of EDI implementation and data dissemination

Sustainability The development and execution of a strategy for long-term sustainability of both elements (direct service delivery and the system-level strategies)

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Staffing Considerations

Outlined below is an example of how to staff the necessary roles to ensure responsibility is assumed for each. These recommendations reflect staffing structures in previous THV implementation efforts.

A coordinator or supervisor for each home visiting program should be hired to provide oversight and management of other home visiting staff. This coordinator will be responsible for hiring and overseeing home visitors who will deliver services to clients in accordance with program model requirements, collect and enter program data, and participate in CQI initiatives and training activities.

System-Level Strategies

One of two staffing structures is recommended for the system-level work: either a single coordinator who will oversee all functions related to early childhood coalition building, implementing the EDI and disseminating the EDI data should be hired. Or, alternatively, separate coordinators can be hired: one to oversee early childhood the coalition building and one to oversee the EDI implementation. Having one coordinator devoted entirely to the EDI is helpful in large communities where there are many school districts to bring on board or when the individual providing oversight on EDI implementation has previous experience with the EDI or collecting community-wide data.

When the early childhood coalition building and the EDI implementation are tasked to different people, it is important that these two individuals work closely together. The purpose of the EDI is to assess community needs, which needs to be reported back to the coalition to develop system-level strategies.

Sustainability

The grantee is responsible for coordinating efforts across the home visiting program models and coalition members to develop a strategy for long-term sustainability. This responsibility has been incorporated both into a role of direct service delivery coordinator and coalition building coordinator.

Implementation Timeline

The timeline for deliverables and performance measures will be outlined in the contract with HHSC. The timeline below is a guide for grantees who are starting new programs and highlights what should be prioritized in the first six months.

First Six Months

1.

Hire direct service staff and complete required evidence-based training per program model requirements

2.

Partner with program model developers to create implementation plans

3.

Develop data collection/tracking processes

4.

Develop a coordinated referral system to ensure successful recruitment of the highest-need families

5.

Design community-specific outreach, recruitment, and retention strategies

6.

Participate in required evaluation activities

Build community readiness through capacity-building activities:

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2.

Identify an existing early childhood coalition to partner with or recruit stakeholders from a variety of sectors

(justice, business, local government, health, etc.) to develop a new coalition with an appropriate structure

3.

Recruit schools to implement EDI

Seven Months – Contract End

Implement home visiting services

1.

Complete ongoing trainings that are required by the program model and HHSC

2.

Collect all required data for the program model, HHSC, and federal funding partners (if applicable) and ensure

timely and accurate input of data

3.

Participate in required evaluation activities, continuous quality improvement initiatives, and professional

development training

Facilitate local coalitions to adopt or build on an existing comprehensive early childhood system:

1. Build interest in and knowledge about early childhood and home visiting with local leaders and key community stakeholders

2. Gain community buy-in by developing/enhancing community level support systems that compliment home visiting services, and are essential for family success (toy lending library, neighborhood playground, etc.)

3. Build agency infrastructure for implementation

4. Develop a plan to leverage local resources that can support implementation

Who to Call with Questions?

HHSC provides support to communities for each of the required elements. A list of resources to contact for help is provided in Appendix A.

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Chapter 3

What are Home Visiting Programs?

The direct service component of this project entails implementing one or more pre-selected evidence-based or promising-practice home visiting program models. HHSC defines home visiting programs as voluntary-enrollment programs, with home visiting as the primary service delivery strategy. Trained early childhood or health (i.e., nurses) professionals or paraprofessionals regularly visit the homes of pregnant women or families with children under the age of six who are at risk for negative outcomes around maternal and/or child health and school readiness and achievement.

Grantees choosing to implement evidence-based home visiting programs must select at least one of the following models:



Early Head Start – Home Based (EHS-HB)



Home Instruction for Parents of Preschool Youngsters (HIPPY)



Nurse Family Partnership (NFP)



Parents as Teachers (PAT)

The choice of program model(s) should be based on, in part, alignment between community needs and the evidence of the model. The evidence base for these four program models is presented in Appendix B. Grantees can also choose to implement a promising-practice program model; defined in greater detail in Appendix B. If a promising-practice model is chosen, no more than 25 percent of total funds awarded across all contracts can be allocated to support promising-practice models.

Who Do I Contact for Assistance?

HHSC has community development specialists on staff to assist communities with implementing and operating home visiting programs. See Appendix A for additional information.

Should I Implement a New Program or Expand an Existing Program?

Grantees can choose to either implement a home visiting program model that is not currently operating in their community (“new”) or expand a home visiting program model that is already operating in their community (“existing”).

Factors that should be considered when choosing to develop a new program include (but are not limited to):

1.

Community need for services (i.e., what unmet needs are in your community that can effectively be addressed

through a home visiting program?)

2.

The likelihood that families would voluntarily participate in services

3.

Community capacity to effectively implement services (i.e., what organizations or agencies in the community

have knowledge of and experience in providing direct service programs?)

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Factors that should be considered when choosing to expand an existing program include (but are not limited to):

1.

Prior effectiveness in service delivery

2.

Demonstrated need for expansion (i.e., has the existing program been operating at full capacity; wait list data,

etc.)

3.

Demonstrated ability to grow community support for the program

4.

Funds will be used to increase the number of families served, not pay for service slots that already exist

5.

Ability to meet the varied requirements and data reporting associated with additional funding sources

Implementation Essentials

1.

Contact the state or program model office for information and material on implementation specific to the home

visiting program model

2.

Hire a coordinator to oversee and manage service delivery, and hire and supervise home visitors

3.

Recruit and retain families

4.

Deliver services

5.

Complete all reporting requirements

Who Should We Target for Recruitment?

Each of the four evidence-based home visiting program models has specific eligibility requirements for who can participate in their program (see Table 3). The Nurse-Family Partnership has the most stringent eligibility requirements: enrollees must be low-income, pregnant with their first child, and must enroll prior to their 28th week of pregnancy. Early Head Start-Home Based also has a strict income eligibility (enrollees must have an income equal to or below the federal poverty line). In contrast, HIPPY and PAT have looser eligibility requirements and allow more flexibility in defining the target population.

Table 3. Program model eligibility requirements

Program

Model EHS-HB HIPPY NFP PAT

Ages served Pregnant women; Children from birth to 3 years. Parents of children ages 3 to 5 years.

Pregnant mothers (home visitors continue serving these mothers until the child is two years old).

Pregnant women; families with children from birth to 5 years.

Target Population Family income at or below federal poverty level Parents who lack confidence in own ability to instruct their children and prepare them for school.

Mothers must be low-income (specific low-income eligibility varies) and pregnant with first child. Enrollment and first visit must occur prior to 28th week of pregnancy.

Eligibility criteria for the target population are defined by each site but may include income-based criteria, children with special needs, teen parents, etc.

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In addition to the eligibility requirements specific to the home visiting program model, there are target populations specific to the federal- and funding sources, which are outlined in Table 4. There is some overlap in the federally- and state-defined target populations (e.g., low-income, teen parents), but there are other risk factors that are unique to each target population (e.g., only MIECHV includes military families as a priority target population). Grantees must target individuals who reside in the eligible geographic area and must provide services to families who have at least one of the risk factors identified in Table 4.

Table 4. Federally- and State-defined target populations

Risk Factor: State-defined (SB 426) Target Population Federally-defined (MIECHV) Target Population

Reside in eligible geographic areas  

Have low-incomes  

Are pregnant women, mothers, or fathers who have not attained age 21  

Have poor maternal health 

Have parental underemployment or unemployment 

Preterm birth 

Low parental education  

Have a history of child abuse or neglect or have had interactions with child welfare

services 

Have a history of substance abuse or need substance abuse treatment 

Have used tobacco in the home 

Have children with developmental delays or disabilities 

Are or have family members who are serving in the Armed Forces 

How Do We Recruit High-Risk Families?

One of the keys to successful implementation of home visiting program models is the capacity to recruit, enroll, and retain participants from the model’s target population. The risk factors—being poor or low-income, a teenage parent, having a history of child abuse, and/or substance abuse—that make families eligible for participation in the programs also make it difficult for the programs to serve and retain them.

Effective recruitment improves with time, which suggests expanding an existing home visiting program may provide an advantage in recruiting and enrolling families, but also suggests that grantees implementing new home visiting programs should not get discouraged if recruitment is challenging in the beginning. The longer a program has been operating, the more time it has to build greater trust and positive reputations in communities, which also leads to more word-of-mouth referrals from other families who have participated in the program. Community members’ increased trust in the programs can also help programs combat some struggles with branding and stigma, particularly in distinguishing themselves from home visits conducted by Child Protective Services (CPS).

Who NOT to Target:

Families in home visiting programs funded by other state agencies or by different funding streams within HHSC should NOT be recruited for THV. Similarly, families should NOT be enrolled in multiple programs within the same community.

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How Do We Keep Families Engaged in the Program?

Retaining families in home visiting programs is essential for improving child and family outcomes, but because home visiting programs target high-need families who have multiple stressors in their lives, keeping them engaged in the program can be particularly difficult. The following strategies are described in greater detail below:

1.

Home visitors should focus on establishing a trusting relationship with their clients

2.

Be clear about program expectations with families at enrollment

3.

Be persistent

In previous implementation efforts, the relationship between the home visitor and the family has been frequently cited as one of the primary ways home visitors keep families engaged. Through building the relationship, home visitors establish trust with their clients, home visitors become a valued source of emotional support and a resource for referrals to services. Many home visitors reported that being explicit about the program expectations and requirements with families at the beginning of the program has proved helpful to retain families. Home visitors have pointed out the importance of ensuring that families saw tangible benefits of their continued participation in the program. Home visitors reported persistent check-ins with families (i.e., calls, texts, and mailings) was successful to keep families engaged.

How Do We Engage in Continuous Quality Improvement?

A critical tool for home visiting programs, the continuous quality improvement (CQI) plan is organized around recognition of a specific problem; planning for, and implementing a change; gathering data on the effects of the change and analyzing results; then taking action based on the data analysis. Effective CQI plans, developed by teams that include local program model supervisors, home visitors and parents, provide a framework for improvement activities that are vital to ensuring consistent and reliable high quality services for parents and children.

New grantees are provided CQI guidelines, tools and resources to reference as they organize CQI teams to conduct process improvement projects. The CQI specialist and community development specialists at HHSC will provide on-going technical assistance to the grantees and CQI teams.

Best Practices for Implementing Home Visiting Programs

Additional best practices for implementation including prioritizing accurate data collection, engaging fathers in home visiting programs, strategic communications, and professional development training are described below:

Prioritize Accurate Data Collection and Entry

Additional detail regarding data collection is provided in Chapter 4, but the importance of accurate data collection and entry cannot be overstated. Accurate data are essential for programmatic decision making, monitoring program model fidelity, and are required to report on performance measures (referred to as “benchmarks” in federally-funded programs). All funding is contingent on reporting demographic and benchmark data. Similarly, state funding requires grantees to collect accurate data to demonstrate progress on performance measures (provided in Chapter 4).

In addition to required data reporting, accurate data collection is essential to helping programs learn about their own service delivery and drive decision-making. Accurate data identify program strengths and areas for improvement.

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The types of questions that can be answered with accurate data are:

1.

Who are we serving?

2.

Are we retaining families?

3.

Which families are dropping out and why?

4.

What services are we providing?

5.

Has service delivery improved over time?

6.

Are families receiving all of the visits they should?

7.

Are we providing services on schedule?

8.

Are families demonstrating improvement over time?

Establish Relationships with Referral Sources

Making connections with other service providers in the community is essential to recruitment and HHSC is available to help grantees make introductions if needed. In previous implementation efforts, sites have recruited families by

establishing relationships with the local schools (particularly those that have special programs for pregnant teens), Early Childhood Intervention (ECI), child care centers, preschools, Child Protective Services (CPS), and other agencies and organizations that serve young children. Relationships with local Medicaid and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices have proved fruitful for many program sites, particularly NFP programs, which can only enroll mothers early in their pregnancy. HHSC can help establish the connections with other agencies that serve young children when necessary. Also, organizing and/or participating in community-wide organizations and events (e.g., libraries, health fairs, and health clinics) are also useful recruitment strategies families.

Develop a Coordinated Referral System

Grantees can also establish a coordinated referral system in their community to ensure that the home visiting program models within a community are connected to each other and are sharing referrals. This coordination can enhance recruitment efforts by reducing lengthy waiting lists of families that could be served by another program. Additionally, by matching families to the most appropriate program models (based on the families’ needs and the programs’ eligibility requirements), families are more likely to enroll and remain in the program.

Developing a coordinated referral system among the home visiting programs, however, can be challenging. Ensuring compliance from the implemented home visiting program models is important. The program models vary in the rigidity of their eligibility requirements and the programs with flexible or less rigid eligibility requirements will likely benefit more from the matching system than programs with very strict eligibility requirements. In previous implementation efforts, at times, this led to frustration among the program models with strict eligibility requirements, particularly among NFP programs, because they received far fewer referrals through the coordinated referral system compared to the other programs in their community.

Engage Fathers in the Program

Increasing father participation in home visiting may benefit children directly by changing fathers’ behaviors toward their children as they learn new parenting skills and develop tools for supporting their child, and strengthen parents’

relationships and co-parenting skills. Engaging fathers in home visiting programs, however, can be difficult. Fathers who do not live with their child’s mother (nonresident) and fathers who are not married to their child’s mother are less likely to participate in programs than their resident and married counterparts, and employed fathers report that they are often unable to participate in programs because the program activities conflict with their work schedules.

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The simplest strategy that programs can use to increase father participation is for home visitors to consistently initiate conversations about engaging fathers with the enrolled mothers. “Invite dad” approaches for engaging fathers in the program also lead to increased father participation. If programs are interested in consistently engaging fathers in the program activities where the curriculum is delivered, including home visits and program activities, the programs may need to take “invite dad” strategies to the next level and employ more flexible scheduling policies to accommodate fathers’ work schedules, which can be challenging if staff need to work in the evenings or on weekends to be accommodating. As a result, programs need to consider their goals related to engaging fathers and determine ways to include fathers in program services.

Develop a Communication Plan

A strategic communications plan can be an important tool in elevating awareness and understanding of the benefits of home visiting and ultimately, in strengthening the impact of the home visiting program in your community. Effective communication begins with a strong strategic plan, developed for your initiative by your partners and stakeholders. A well-crafted plan provides a road map for your communications activities and can be a vital component for your program’s long-term success.



Each existing community has received the Strategic Communications Planning Guide and marketing materials.

New communities will also receive the guide and materials to develop a well-conceived communications plan.

THV program communications specialist and community development specialists will provide technical

assistance with online and print collateral (i.e. advertising, working with media, brochures.) The following are

cited in the THV communications guide: Assessment/goal setting



Audience identification



Messaging development



Message delivery



Implementation



Measurement



Resources



Communications Toolkit



Worksheets



Social media guide



Marketing materials

In addition to the THV communications guide mentioned, each program model has its own verbiage and messaging guidelines. It is vital to be in compliance with messaging and communications guidelines set by the program model your program is implementing.

Prioritize Professional Development

Professional development is an important aspect of the THV. The purpose of providing professional development is to increase the knowledge, understanding, and development of professionals that provide home visiting services across Texas.

HHSC has a full-time Training Specialist on staff to manage HHSC-sponsored professional development. The Training Specialist is also available to help home visiting staff research and identify high-quality professional development opportunities in each respective community.

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Table 5 provides a description of possible training topics and training delivery methods. The training topics and delivery methods are subject to change based on budget and/or community training needs.

Table 5. Possible training topics and delivery methods

Possible Training Topics

1.

Infant, Child, and Adolescent Development

2.

Family Systems & Dynamics

3.

Relationship-Based Practice

4.

Family Health & Safety

5.

Cultural and Linguistic Responsiveness

6.

Professionalism and Ethics

7.

Service Planning, Coordination, and Collaboration

8.

Leadership

9.

HHSC Program Operations

Possible Training Delivery Methods

1.

Program Model Training:

Training provided through Parents as Teachers (PAT), Home Instruction for Parents of Preschool Youngsters (HIPPY), Nurse Family Partnership (NFP), and Early Head Start Home-Based (EHS-HB)

2.

In-person Training:

Offered in Austin and/or local communities

3.

Online Training/Webinars:

High-quality training available free-of-charge online, and/or specific training that will be developed for Texas Home Visiting

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Chapter 4

Data Collection

Grantees are required to complete specific outputs and outcomes, which will require accurate data collection and prompt data reporting. Some data collection is specific to the home visiting program model. Guidance for these processes and for ensuring model fidelity will be provided by the program model leads. Guidance for THV data collection that is specific to either federal or state grant funding is provided here.

Data Collection Responsibilities

The demographic and program data that home visitors collect during home visits with their families are entered into the data system specific to the home visiting program model, which is then confidentially and securely aggregated into the THV data collection system. Data are also collected via monthly and quarterly reports submitted to HHSC by the grantee. These data provide updates on family enrollment, staffing, and program activities. In addition, data related to evaluation activities are collected via surveys of and interviews with home visiting program staff and families. These data collection activities are highlighted later in the chapter on evaluation activities (Chapter 7).

Overview of the THV Data Collection System

The THV data collection system (shown in Figure 2) aggregates the data entered by home visitors in the home visiting program model’s data management system (Visit Tracker for EHS-HB, HIPPY, and PAT; ETO for NFP). Because the THV data collection system pulls information from each of the data management systems, it eliminates duplicative data entry allowing HHSC to obtain the required data without increasing burden on home visitors and program sites.

*HRSA (Health Resources and Services Administration) is the federal agency from which Texas Home Visiting receives a portion of its funding.

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Ensuring Data Quality is Critical

There are two primary factors that compromise data quality: missing data and inaccurate data. When data are missing and/or inaccurate, the great work of home visiting program model staff is not reflected and it is difficult (and sometimes impossible) to:

1.

Evaluate outputs and outcomes

2.

Use data to drive programming decisions

3.

Fulfill data reporting responsibilities

4.

Show trends

5.

Evaluate the program

6.

Demonstrate program success

Who Do I Contact for Assistance?

HHSC has data specialists on staff to assist communities with the THV data collection system and any data-related issues. Grantees can also reach out to the home visiting program model leads. See Appendix A for additional information.

For Which Outputs and Outcomes Do I Collect Data?

Outputs

Grantees must collect accurate data via the THV data collection system and the monthly and quarterly reports to ensure that they meet ALL of the following outputs (the specific target for outputs indicated with a * is negotiated with HHSC):

1. The expected number of families are served annually* 2. The expected number of children are served annually*

3. 100 percent of staff are trained to deliver the evidence-based model

4. Program will maintain 85 percent family capacity throughout the contract period 5. Program will ensure broad participation in a local early childhood coalition*

6. 100 percent of continuous quality improvement (CQI) activities are conducted annually 7. The Early Development Instrument will be used to identify community needs*

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Outcomes

The specific outcomes for which grantees must use data to demonstrate progress vary depending on funding source.

SB426 outcomes

Grantees receiving funding through SB426 must meet two or more of the following outcome measures, which are provided in greater detail in Appendix C:

Maternal and Child Health Outcomes

1.

Women will breastfeed for at least six months postpartum

2.

Children will attend recommended well-child visits

3.

Babies will be born at full term

School Readiness

Outcomes

4.

Parents will increase the number of days per week that they read to or

with their children

5.

Parent-child relationships will improve

6.

Primary caregiver(s) will increase their ability to cope with parental

stress

Family

Self-Sufficiency

7.

Primary caregiver(s) will increase hours working or in education

MIECHV outcomes

Outcomes associated with the federal (MIECHV) funding are referred to as benchmark outcomes. There are six federally-defined benchmark areas and a total of 35 performance measures across the benchmark areas. These are provided in greater detail in Appendix C.

Grantees receiving MIECHV funding should demonstrate progress toward each of the following benchmark areas:

Benchmark I. Improved Maternal and Newborn Health

Benchmark II. Child Injuries, Abuse, Neglect, or Maltreatment and Reductions in Emergency

Department Visits

Benchmark III. School Readiness and Achievement

Benchmark IV. Domestic Violence

Benchmark V. Family Economic Self-Sufficiency

Benchmark VI. Coordination and Referrals for other Community Resources and Supports

Data 101

The relationship between the individual program model databases and the THV data collection system is described in greater detail in the Data 101 manual. Also provided in the Data 101 manual is additional information about navigating the THV data collection system to pull reports, the importance of complete and accurate data, other ways data can be used to inform decisions and what types of data may be interesting to different audiences.

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Chapter 5

Implementing System-Level Strategies

In addition to providing direct home visiting services, grantees must implement system-level strategies that address broad policy, practice, or community infrastructure issues that impact young children/families and benefit the community at-large. Implementation will involve developing or enhancing early childhood coalitions, administering the Early Development Instrument (EDI), and coordinating cross-sector services to create a “no wrong door” approach for families needing services. HHSC has community development specialists on staff to provide assistance with coalition building, EDI implementation, and any other systems-level work topics (Appendix A).

Develop or Enhance an Existing Early Childhood Coalition

Grantees should identify an existing early childhood coalition to partner with or recruit stakeholders from a variety of sectors to develop a new coalition with an appropriate structure. The purpose of these coalitions is four-fold:

1.

Identify community-level needs as related to school-readiness and maternal/child health outcomes

2.

Integrate services to create streamlined access across different sectors

3.

Implement system-level strategies that address broad policy, practice, or community infrastructure issues that

impact young children/families and benefit the community at-large (enhance the public transportation system,

improve family-friendly business policies, increase access to community parks/playgrounds, etc.)

4.

Build relationships with key stakeholders to create a foundation for long-term sustainability

Coalition Building Essentials

1.

Identify key early childhood services in the community

2.

Recruit coalition members

3.

Recruit community leaders to form the leadership subcommittee/steering committee

4.

Develop a vision and mission for the coalition

5.

Develop a structure and processes for the coalition which include long-term strategic planning and

documentation

Who should be engaged in the coalition?

Early childhood coalitions should engage various stakeholders including: various service providers, business leaders, political champions, foundation partners, faith-based entities, city/county government, school districts, and public health stakeholders. Communities should identify partners that have local influence and the ability to transform community systems.

Staff from home visiting programs can be included as stakeholders in the coalition, but should NOT be the focus of the coalition. In previous implementation efforts, confusion about the role of home visiting programs relative to other

stakeholders in the coalition has occurred because the funding for both direct service implementation and systems work comes from the same grant. The coalition does not exist to solely support home visiting programs, rather, home visiting program staff should have a role in the coalition equal to other cross-sector service providers.

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How should the coalition be structured?

Communities should develop a coalition structure that will effectively engage different stakeholders for varying purposes (i.e., business champions may participate on policy/fund development components as opposed to service integration strategies, and attend targeted meetings as opposed to monthly meetings). The coalition should NOT require partners to attend every meeting or work on all four broad purposes (e.g., identifying community needs, integrating services,

implementing strategies, etc.), but instead include a variety of engagement strategies that best utilize the skill-sets of the specific stakeholder groups.

Identify Community-Level Needs

The early childhood coalition must use local-level data to identify and address local needs. To identify these needs, coalitions must work to collect community-wide data around child health and well-being, including the Early Development Instrument (EDI). In addition to the EDI, HHSC can assist grantees in accessing other sources of community-level data.

The Early Development Instrument

The Early Development Instrument (EDI) is a population measure of young children’s development as part of the national Transforming Early Childhood Community Systems (TECCS) initiative. The EDI is a kindergarten teacher-completed questionnaire that consists of 103 core items measuring five developmental domains, including, (1) physical health and well-being, (2) social competence, (3) emotional maturity, (4) language and cognitive skills, and (5) communication skills and general knowledge. HHSC will provide each awarded community with the EDI assessment instrument, training, and technical assistance.

How Will the EDI Data Be Used in My Community?

The primary aim of the EDI is to provide a community-level indicator of child development and well-being that will help communities transform their local early childhood service systems. The data can be used by communities to establish their baseline about how children in each community are doing in each of the EDI’s five developmental domains. The implementation process can be used to develop and strengthen relationships between agencies and stakeholders in the community. Results from the EDI and other local indicators can also facilitate community mobilization, planning, and action.

EDI Implementation Essentials

The following are key steps involved in implementing the EDI in your community. These are meant as general

recommendations to help with planning and implementation – the process should be adapted to the local community’s needs, privacy requirements, and educational policies.

Designate an EDI Coordinator

The grantee is responsible for designating an individual to serve as the EDI coordinator. This individual will be the lead contact for receiving and requesting technical assistance and will coordinate local activities between community partners, school districts, and local coalitions using the EDI data.

Identify target geography

The goal of the EDI is to achieve a full census on children’s school readiness in the target geographic area. This target area is sometimes limited to just a few neighborhoods, but ideally it should encompass at least a city or county to achieve a more comprehensive picture of children’s relative strengths and challenges to better inform planning.

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Recruit districts, principals, and teachers

Partnering with school districts is one of the first tasks because the EDI requires kindergarten teacher participation. Depending on the size and structure of the district, the EDI coordinator may approach school district administrators or focus recruitment efforts on individual school principals to recruit teachers. It is recommended that all of the schools serving children in the target area be recruited in order to achieve a near census of the EDI results. This could mean involving more than one district or recruiting some schools that are not located in the target geography.

Additional assistance on the following issues related to recruiting districts, principals, and teachers will be provided by the technical assistance provider:

1.

How to establish contact with the school districts

2.

How to demonstrate benefits of EDI to the school districts

3.

How to discuss the logistics of when teachers will participate in the EDI training and assessment and how

parents will be informed

4.

Selecting a district EDI Coordinator, who will make many of the district-level logistical decisions regarding EDI

implementation

5.

How to formalize the relationship with the school district through Local Memorandums of Understanding

(MOUs), contracts, or gaining IRB approval, if necessary

6.

How to recruit schools and teachers once the school district agrees to participate

Prepare and conduct teacher trainings

Standardized training for teachers is critical for reliable comparisons across sites. Most often, to minimize burden on the school district, the EDI coordinator trains the teachers, not the district staff. The EDI coordinator will receive all of the materials needed to conduct teacher trainings from the technical assistance provider.

The primary purpose of the teacher training session is to outline the importance of the EDI effort and show kindergarten teachers how to complete the EDI forms in the e-EDI online system. These forms include an electronic teacher consent form, an EDI questionnaire for each child in his or her class, and a teacher feedback form.

Complete the EDI (done by teachers)

On average, it takes teachers 10 to 15 minutes to complete one EDI. Teachers use recall to complete the EDI so students are not present when the teacher fills it out. The EDI is completed no sooner than three months into the school year to assure that teachers have had ample opportunity to observe their students’ development. Most commonly, teachers complete the EDI in January or February of the kindergarten year. This is particularly important for the social and emotional domain items. When teachers try to answer these question too early in the year, they tend to select “don’t know” at a much higher rate.

Generate EDI results

Each community will receive a child level, de-identified and scored data file along with a data dictionary and instructions for using the data. The data file allows local data analysts to create EDI reports and maps and to do additional and more customized local data analyses.

Communities will also receive the EDI Community Profile—the most detailed source of information on local EDI results— in a series of detailed tables and maps with explanations that depict neighborhood EDI child results.

Using the EDI data

Community data from the EDI should be used in the coalition to develop a strategic plan for improving children’s

readiness for school. The EDI coordinator should disseminate EDI findings to the broader community in addition to school districts serving the community.

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Additional Community-Level Data Sources

In addition to implementing the EDI, communities may access additional community-level data to help inform local needs. Other sources of community-level data include, but are not limited to:

Texas KIDS COUNT Data Center

Current and reliable child well-being data related to education, employment and income, health, poverty, and youth risk factors are available for the U.S., Texas, and all of Texas’ 254 counties as well as for many congressional districts. All data are available online at: http://datacenter.kidscount.org/

Texas State Data Center

Current population estimates and population projections for by age, sex, and race/ethnicity for Texas and all of Texas’ 254 counties. All data are available online at: http://txsdc.utsa.edu/Index.aspx

HHSC has a data specialist on staff that can help connect you with resources, interpret results and/or identify additional research.

Create a “No Wrong Door” Approach

Integrating local service providers helps ensure coordinated access to the various service systems that impact young children and families (e.g., home visiting, mental health, employment, school, etc.). That is, families can access any service provider and be referred to appropriate services based on family need eligibility.

How Do We Create a “No Wrong Door” Approach?

The following activities will help coordinate services across providers to create an effective continuum of services for families:

1.

Develop coordinated referral systems to ensure families can easily access services that best meet their needs

2.

Identify and implement community-wide recruitment/retention strategies

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Chapter 6

Sustainability

As with all funding sources, neither the federal nor state funding for the direct service delivery or for the systems work are guaranteed long-term. Each community must work collaboratively to leverage resources that sustain the full

service/system continuum that best meets local needs. The following are tools to assist in sustainability planning. Each community should develop a sustainability plan that includes:

1.

Identified potential revenue-generating strategies with targeted goal amount

2.

A timeline for specific strategies

3.

Requests for support from HHSC

Potential Revenue-Generating Strategies

For each revenue-generating strategy identified, indicate the minimum amount that is likely to be received and the maximum amount (the ideal amount), indicate who will take the lead on the strategy, and indicate any assistance that HHSC could provide.

Possible funding strategies include:

1. Government-Identify any local government funding and/or other state funding that is well-aligned with your work.

Indicate the deadlines for submitting any requests for funds.

2. Private Grants-Indicate specific foundations or entities in your community that fund the strategies that you are

seeking to sustain. Indicate the minimum/maximum amounts based upon their history of giving (typical award size). Indicate deadlines for grant submission.

3. Direct Corporate Gifts-Indicate specific corporations in your community that support your strategies and indicate

deadline by which you will make the ask.

4. Earned Income-Identify any opportunities to provide fee for service type activities with the associated deadlines

by which you will have the funding in hand.

5. Special Events-Identify any special events that you will coordinate to raise funds with the deadline indicating the

projected date of the event.

6. Gifts-Indicate different types of audiences that can make individual gifts, including corporations in your

community that match employee gifts.

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Best Practices for Fundraising for Collective Impact

Fundraising is an essential platform in a community engagement process. Raising funds creates conversations with leaders, who, over time, come to believe deeply in one’s work. These leaders can help engage key influencers in a community who, in turn, can assist in turning ideas into realities. The following best practices come from the Raising Funds, Finding Friends for Collective Impact workshop developed by the Tamarack Institute1:

1.

Identify the collective passion and articulate it – this is what people invest in. A common agenda owned by a

whole community is highly desirable for funders.

2.

Get ready to receive money. People do not invest in confusion or incompetence. Have the correct systems in

place so that when investments are received they are processed in a professional manner.

3.

Build relationships and then build the relationship – people give to people in whom they trust. Invite donors in

early.

4.

Communicate the opportunity to invest as an invitation to engage and learn. Projects seldom go as planned.

Engage funders in the work as it unfolds, so they will be better able to recognize successes while understanding

the challenges faced.

5.

Momentum builds with growth in credibility, capacity, and capital for the project.

HHSC Community Development specialists can help with this undertaking. Additionally, resources are available to help with research, grant preparation, and other related activities to support this effort.

1

Born, P. Friendraising: Raising Funds, Finding Friends to Realize Bold Community Visions. A Workbook. Tamarack Institute. Retrieved from: http://tamarackcommunity.ca/downloads/tools/friendraising.pdf

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Chapter 7

Evaluation

Overview of Evaluation Activities

HHSC contracted with the Child and Family Research Partnership (CFRP) at the LBJ School of Public Affairs at UT Austin to evaluate the implementation and outcomes of THV (Texas Nurse Family Partnership is excluded from the evaluation). CFRP is conducting an ongoing program implementation evaluation (PIE) study of THV and analyzing the extent to which THV is showing improvement in benchmarks established in collaboration with the federal funding agency (U.S.

Department of Health and Human Services Health Resources and Services Administration; HRSA). In separate

evaluation studies, CFRP is evaluating communities’ engagement of fathers in home visiting services and factors related to family retention in home visiting programs.

All THV communities participate in PIE (described in greater detail below), but many grants have specific corresponding evaluation components. This means that participation in certain evaluations is required only for those communities receiving funding from a particular grant. The evaluations associated with each round of grant funding are provided in Table 5.

Table 6. Grant funding and corresponding evaluations

Grant

Evaluation Year and Type HHSC ID Award #

FY10 Formula H5CG X02MC21581-01-03 Program Implementation Evaluation (PIE)

FY11 Competitive H5CH D8923159-01-02 Father Participation Evaluation (FPE)

FY11 Formula H5CJ X0MC23132-01-03 PIE

FY12 Formula H5CJ2 X0MC23132-01-05 PIE

FY12 Competitive H5CH2 D8923159-02-03

FY13 Competitive

Expansion H5CH3 D8926366-01-01

Father Participation and Retention Evaluation (FPRE)

FY15 Formula H5CJ5 HRSA-15-101 PIE

FY15 Competitive H5CH4 HRSA-15-102 PIE; TBD

Senate Bill 426 H5CV SB 426 PIE

Overview of the Program Implementation Evaluation

The overarching aim of the program implementation evaluation (PIE) is to better understand both the factors that enhance and those that limit the ability of home visiting program models to effectively scale-up and produce positive outcomes for families with young children. The goal of the evaluation is not to evaluate any one program model or to evaluate a

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particular community, but rather to understand at the state level, what it takes to bring home visiting programs to scale. The five overarching aims of the program implementation evaluation are to determine:

1. Is there variation in the services delivered to families and in family outcomes across the THV programs? 2. To what extent does the identified variation in outcomes differ from what should be expected from the prior

research and the program models’ randomized controlled trials (RCTs)?

3. Does variation in implementation (e.g., the motivations and capacities to participate in THV; program infrastructure and staffing; communication, trainings, technical assistance; and marketing and outreach) or variation in the THV elements (e.g., coalition building, the use of the EDI; the development of a no wrong door approach; continuous quality improvement efforts; or efforts to increase father engagement in home visiting) account for the variation in service delivery across THV programs?

4. To what extent does the variation in service delivery explain variation in family outcomes across the THV programs?

5. What policy implications for future implementation and scale-up efforts emerge from the implementation of THV?

Data Sources

The data used to conduct this mixed-method evaluation come from a variety of sources. The primary source of

quantitative data is the THV data collection system, which includes demographic, enrollment, and benchmark information. Qualitative data come from various THV documentation and materials, observations of THV-related activities, monthly and quarterly reports, and interviews with the four state home visiting program model leads, the community grantees, and staff from the home visiting programs.

Texas Home Visiting data collection system

Each home visiting program participating in THV collects demographic information on participating families along with data on child and maternal health, child injuries and emergency room visits, school readiness and achievement, domestic violence, family economic self-sufficiency, and referrals for other community resources and supports. Each home visiting program is responsible for logging this information in addition to family enrollment, visit, and exit data into their respective data systems. The data from the home visiting programs’ data systems is imported into a central system (the THV data collection system), from which CFRP can securely access the data. The demographic and benchmark data are the primary source of data for assessing variation in the components of service delivery.

Observations of THV-related activities

HHSC and the communities participate in numerous conference calls, technical assistance meetings, trainings, and coalition activities. CFRP observes these activities either in person or over the phone and takes extensive notes. All notes are stored confidentially and securely. The researchers analyze and code notes from the observations on an ongoing basis, and continually update findings.

Members of the CFRP evaluation team also observe conferences and trainings that include the grantees, home visitor coordinators, or the home visiting state program model leads within each community. Finally, CFRP observes all webinars provided to community grantees by HHSC or state-level grantees.

Monthly and quarterly community reports

HHSC requires the grantee in each of the communities to submit monthly reports on behalf of each of the home visiting program models in their respective communities. The monthly reports provide updates regarding staffing, the number of participants enrolled in each home visiting program model, and the program models’ maximum caseloads at that point in time. Grantees also report their communities’ major accomplishments, plans for the upcoming months, resource

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In addition to the monthly reports, HHSC requires grantees to submit quarterly reports to obtain additional information about the communities’ progress toward THV goals. The quarterly reports provide documentation on staffing and infrastructure, the communities’ major accomplishments and challenges for the quarter, the communities’ goals and objectives, the number of MOUs established, recent communications with local social service agencies, and CQI initiatives during the quarter.

Interviews and community visits

CFRP conducts semi-structured, open-ended interviews (over the phone or in person) with individuals from HHSC, state program model leads, community-level program managers, and community-level home visiting program coordinators and home visitors. The purpose of these interviews is to hear from THV participants about their experiences implementing THV. Questions are both broad (e.g., How are things going for your community?) and more specific (e.g., Can you provide an update on where you are in implementing the matching system in your community?). Participants typically provide a brief update on each element of THV and any deliverables (e.g., sustainability plan), including successes and challenges they have experienced.

Surveys of home visitors and enrolled families

Improving the quality of the data in the THV data collection system is ongoing. To supplement those data and to collect more specific information about home visitors’ experiences providing services to families and families’ experiences participating in home visiting programs, CFRP conducts periodic surveys of home visitors and families. Occasionally, CFRP conducts focus groups with specific sub-groups of participating families (e.g., fathers, teen parents, etc.) to ensure the perspectives of all participating families are reflected.

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Chapter 8

Lessons Learned

The evaluation of the previous THV implementation efforts has highlighted important lessons learned that can provide helpful guidance for successful new implementation efforts.

Accurate and Timely Data Collection and Entry are Essential

As noted in Chapter 3, accurate data are essential for programmatic decision making, continuous quality improvement, monitoring program model fidelity, and required reporting on performance and benchmark measures. Federal (MIECHV) funding is contingent on reporting demographic and benchmark data. Similarly, state funding requires grantees to collect accurate data to demonstrate progress on performance measures.

In addition to required data reporting, accurate data collection is essential to helping programs learn about their own service delivery and drive decision-making. The types of questions that can be answered with accurate data are:

1.

Who are we serving?

2.

Are we retaining families?

3.

Are we achieving the intended dosage

4.

What services are we providing?

5.

Has service delivery improved over time?

6.

Are we providing services on schedule?

7.

Are families demonstrating improvement over time?

Accurate data are tools to identify program strengths and areas of improvement and allow for monitoring of service delivery.

Recruit Families with Intention

As emphasized in Chapter 3, be explicit with families about the program expectations and requirements at enrollment. Home visitors have reported that setting clear expectations is a helpful strategy for retaining families because families know what they are getting themselves into from the beginning. Some programs struggled with retention because they recruited very quickly in the beginning in order to fill their home visitors’ caseloads. Even though they were enrolling families who met the programs’ eligibility requirements, they did not often get an opportunity to very clearly explain the level of commitment required by the program. Many families eventually dropped out because the time commitment or the expectations became too great.

The Home Visitor-Client Relationship is Key to Retention

The relationship between the home visitor and the family has been frequently cited as one of the primary ways home visitors keep families engaged. Through the relationship and trust the home visitors establish with their clients, home visitors become a source of emotional support and a resource for referrals on which the clients depend. Many families who have participated in THV have cited the home visitor-client relationship as the part of the program they valued the most.

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Home visiting program coordinators should look for individuals who have good relationship and people skills when hiring home visitors. Home visitors should prioritize building trust with their clients, but also taking care to establish appropriate boundaries. Home visitors should be