One cornerstone of most community health programs, and model element 6 of the Nurse-Family Partnership program, is that the visits are conducted in the client's home. 4 Home visits involve highly trained professionals putting mothers and, ultimately, their children, in touch with resources and community services within the privacy, safety and comfort of their home base. Home visitations are a personal business. Additionally, access to community resources is a significant problem for the mothers in The Children’s Shelter’s Nurse-Family Partnership program because they lack reliable transportation. Homevisitation dissolves that barrier.
The Community Collaboration for Children (CCC) program is a complex initiative implemented in Kentucky by a network of state and non-governmental agencies that provide intensive in-home services to families at risk for child abuse and neglect. The primary focus of this program is to maintain children who are at risk of being removed from their family, in their own homes while supporting and building family strengths in areas such as safety, stability, and interaction skills. The program’s evaluation research design is longitudinal, data was collected quarterly by the services providers, social and child workers. This paper focuses on the validation of the North Carolina Family Assessment Scale (NCFAS), using the intake data collected from 1959 families who participated in the CCC intensive in-home services during July 1, 2006 through December 31, 2009. NCFAS is a practice tool utilized by service providers to assess families on five domains: environment, child wellbeing, family interaction, family safety and family capability as related to child wellbeing. The factors extracted using two approaches - general factor analysis and a congeneric, single-factor analysis- were used to test the predictive ability of each subscale using logic regression analyses, while controlling for the intensity of in-homevisitation services. Both factor analysis approaches yielded valid and reliable results. Of the five NCFAS domains, the family interaction was the strongest predictor of case outcome, assuming that families are provided with 11 to 20 hours of services.
staff. The evaluation design is complex because of the combination of multiple evidence-based models and the “ real- world ” incorporation of a menu of ser- vice options for families presenting with a variety of concerns and challenges. Continual education about the bene ﬁ ts of homevisitation and awareness of the BHC program within participating med- ical practices is essential to maintain a core of enthusiastic and supportive providers. In addition, because BHC does not have a physical presence within the medical practices, the quarterly updates and EMR messages are essential to maintain a “ virtual ” presence. Local funding for BHC has remained consistent since inception, allowing for continuous service delivery. However, federal fund- ing has ﬂ uctuated signi ﬁ cantly, neces- sitating several modi ﬁ cations to the
The DOVE is a multistate longitudinal randomized clinical trial testing the ef- fectiveness of a structured IPV inter- vention integrated into HD perinatal HV programs. The DOVE intervention, based on an empowerment model, combined 2 evidence-based interventions: a 10-min- ute brochure-based IPV intervention and perinatal nurse homevisitation. Participants were recruited from an urban East Coast HD, 12 rural mid- western HDs, and 1 midwestern rural Nurse Family Partnership (NFP) pro- gram. Eligible participants were English- speaking women, # 31 weeks ’ gestation, reporting abuse within the last 12 months, and currently enrolled in a perinatal HV program of a participating HD. Referrals for the study were re- ceived from the participating HDs, and the DOVE research team contacted all referred women. Women were scree- ned for IPV using the Abuse Assessment Screen 15 and the Women ’ s Experi-
randomized trial of a homevisitation service known as Early Start. The results of the trial showed that homevisitation by the Early Start program resulted in small but pervasive benefits in parenting behaviors in the areas of child health, preschool education, positive parenting, nonpunitive parenting, child abuse, and child externalizing and internalizing behaviors. The trial re- sults focused on outcomes for children, however, and an analysis of the program impact on parental and family functioning was not presented. There are 2 reasons why these outcomes are of interest. First, the focus of most homevisitation programs is on promoting family well- being in general. Second, and more importantly, there have been continued suggestions that changes in family social, emotional, and economic functioning are prereq- uisites for changes in child health and well-being. 2–4
LIAISON WITH PRIMARY PROVIDERS Home visitors can be health care advocates to im- prove access to providers of health care. Home visi- tors can be partners with pediatricians and other clinicians, working in the home setting to provide essential education and supportive services to at-risk children and families and to improve adherence to medical prevention and treatment regimens. Home- visitation programs include a “degree of social sup- port that is difficult to provide in most clinical set- tings; outreach and liaison between the pediatrician, the family, and the community; involvement with socioeconomic issues that directly affect the well- being of the child and family; reinforcement and follow-up of preventive care, peer helper support, as well as encouragement, by the home health visitor who has the advantage of being with the family in its own home—a more accepting, less threatening set- ting for the family.” 6
Children in low SES families are at increased risk for reading problems due to deficient oral language skills (Honig, 1982; Walker, Greenwood, Hart, & Carta, 1994) and deficient phonological awareness (Nittrouer, 1996). Some researchers have speculated that the learning of language is constrained by the low values placed upon language in most low-SES sociolinguistic communities (Purcell-Gates, 1995) as well as by parental input that is more directive and immediate (Laosa, 1980, 1982). Lower SES homes are less likely to offer such important home literacy behaviors as shared reading, children’s reading materials, age of onset of shared reading (Lonigan, 1994). The quality of parent to child language can also be influenced of ethnicity, gender and maternal language. This study aimed to reduce the widening educational gap that faces Latino students. It used homevisitation to enrich the home language and literacy activities during children’s early preschool years. Home visits provided parents and children with sustainable Spanish language and literacy materials and were spread over 46 weeks of homevisitation. The data indicate significant gains in receptive and expressive Spanish language ability. There is also evidence that the parents sustain their enrichment activities at least one year after the program is com- pleted. Like the immigrant parents studied by Farver, Eppe and Ballon (2006), the Latino immigrant parents in this study were able to make the language and literacy environments in their homes begin to approximate mid- dle-class mainstream culture, The data also provide evidence that as kindergarteners, the treated children kept their Spanish advantage yet also developed an advantage for spoken English and literacy skills.
We developed a complex, community-based IPV inter- vention to enhance the effectiveness of an existing, pro- ven-effective program of nurse homevisitation, the Nurse-Family Partnership, for a subgroup of families in which the woman has experienced recent IPV. A strength of our approach lies in the systematic process used to develop the intervention, in which we drew on multiple perspectives of NFP clients, nurses and com- munity stakeholders, and current theoretical, empirical and practice literature to inform both the content and process of the intervention, and ground it within the context of the NFP and current knowledge related to best practices in nurse home visiting, and in woman- and child-focused IPV intervention delivery. A rigorous approach to conducting qualitative research was imple- mented thus promoting the overall trustworthiness of the findings upon which the intervention was developed. Data credibility (or internal validity) was strengthened through member checking, data source, data type and researcher triangulation, and reflexivity. Although data were only collected from NFP sites located within the mid-west region of the US, the use of maximum varia- tion sampling provided the opportunity to identify com- mon themes and experiences across a diverse range of sites, nurses and clients.
To improve the health of children and bend the health care cost curve we must integrate the individual and population approaches to health and health care delivery. The 2012 Institute of Medicine (IOM) report Primary Care and Public Health: Exploring Integration to Improve Population Health laid out the continuum for integration of primary care and public health stretching from isolation to merging systems. Integration of the family-centered medical home (FCMH) and homevisitation (HV) would promote overall ef ﬁ ciency and effectiveness and help achieve gains in population health through improving the quality of health care delivered, decreasing duplication, reinforcing similar health priorities, decreasing costs, and decreasing health disparities. This paper aims to (1) provide a brief description of the goals and scope of care of the FCMH and HV, (2) outline the need for integration of the FCMH and HV and synergies of integration, (3) apply the IOM ’ s continuum of integration framework to the FCMH and HV and describe barriers to integration, and (4) use child developmental surveillance and screening as an example of the potential impact of HV-FCMH integration. Pediatrics 2013;132:S74 – S81
In our view, what is required is an increased in- vestment into research and development to under- stand more clearly the features that go into making programs successful and the features that mitigate against program success. The results of research to date suggest that although homevisitation may have beneficial consequences for children and families, in many cases, seemingly well-designed programs fail to deliver their expected benefit. Finding out what makes programs work or fail is a matter of higher priority than the current practice of implementing homevisitation programs on the basis of advocacy, hope, and the inconsistent evidence from current randomized trials.
We developed a case management intervention using homevisitation to increase access to WCC (and immunizations) during the first year of life. Unlike more intensive homevisitation programs, our inter- vention did not seek to transform the home environ- ment or to deliver health care services in the home. Rather, it was designed to bring case managers to the home to facilitate their work with mothers of young children. We evaluated this intervention with a ran- domized, controlled study design in a low-income urban African-American population that we had pre- viously found to have low immunization rates. 37 We
program that was developed and extensively evaluated in the United States. The NFP intervention starts early in pregnancy with intensive and purposeful home visits that continue until the child’s second birthday. There are specific program elements outlined for nurses, super- visors, and organizations involved in implementation of NFP. This includes guidance and requirements for client enrollment criteria, intervention delivery, home visit con- tent, nurse/supervisor education, supervision and team activities (See Table 1) [8, 9]. An extensive process eva- luation is currently being conducted in British Columbia, Canada to document how NFP is implemented and deli- vered within this context . The process evaluation is adjunctive to the British Columbia Healthy Connections Project (BCHCP), the first Canadian randomized con- trolled trial (RCT) evaluating the effectiveness of NFP . If the intervention is shown effective, the findings from the process evaluation will be used to inform adap- tations necessary to ensure that this program meets the needs of Canadian mothers, reflects PHN competencies, and is feasible to deliver across a range of geographic con- texts [8, 11]. The purpose of this analysis, grounded in data collected as part of the broader process evaluation, was to explore and understand the influence of rural geo- graphy on the delivery of the NFP program in British Columbia, Canada.
utilization remains a formidable and costly challenge to the US health care system. Although the CHW intervention has been proposed as a means to improve health outcomes among disadvantaged children, to the best of our knowledge few studies have examined the effects of such interventions on ED visits. Our findings show that this EMHI using trained CHWs directly integrated into the primary care medical home is one way to reduce ED utilization for preventable conditions. These findings are particularly important as the US health care system moves increasingly toward a value-based purchasing environment.
calls that occurred between mothers and Family Coaches between PAT ses- sions. Text messages were sent twice per day, with 1 message prompting mothers to use a speci ﬁ c PAT strategy or to engage in positive interactions with their child, and a second text inquiring about mothers ’ use of PAT, their imple- mentation of a planned activity or interactions with their child, or their child ’ s behavior. Text message content was individualized for each mother and related to the focus of recent in- tervention visits. Interspersed with text message prompts and questions were messages with suggestions for low-cost or free activities within the community and supportive messages to the mother that did not directly pertain to the in- tervention (eg, providing resources or praising mothers ’ efforts). Family coaches called mothers once per week be- tween home visits to engage mothers in talking about their use of PAT or their interactions with their child. Mothers directed the content of the calls, which occurred at times convenient for the mother.
The results of this 9-year trial show that programs like Early Start can produce modest changes in outcomes relating to childhood well-being, including un- intentional injury, harsh discipline, parenting competence, and child be- havior; however, these bene ﬁ ts do not generalize to family-level change. In part, these results are likely to re ﬂ ect the fact that Early Start, as well as other home-visiting programs with similar features, provide advice and mentor- ship but do not provide direct thera- peutic support. These considerations suggest that future directions in this area should involve the closer in- tegration of home-visiting services like Early Start into organizations providing health, educational, and behavioral support. Under ideal circumstances, home-visiting teams should be part of integrated organizations of medical practitioners, educationalists, and psy- chologists that provide integrated sys- tems of care and support for families facing multiple challenges.