- Caroline K. P. Roben, Ph.D., University of Delaware
- Amanda H. Costello, Ph.D., University of Delaware
Evidence-based home visiting is a critical service that effectively improves child and family well-being.1,2 Yet, while millions of pregnant people and families with young children could benefit from evidence-based home visiting services, the majority of those families remain unserved because of resource limitations.3Home visiting is a voluntary federally- and state-funded service in families’ homes that provides expectant parents or parents of young children with support to promote parental and child well-being.3 The COVID-19 pandemic required the home visiting field to pivot from in-person to virtual service delivery to meet the needs of families.4-6 Even when in-person visits were restricted, home visitors were able to reach families and implement programs through virtual connections, maintain relationships, and improve family outcomes.7-10 The COVID-19 pandemic underscored the importance of high-quality home visiting to meet family needs, and highlighted the necessity of greater flexibility and increased funding through the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Allowing versatility, including virtual service delivery as an option (in addition to in-person services) for MIECHV-funded programs, will expand opportunities to reach parents and children with tailored, high-quality services.11
Home Visiting Promotes Positive Outcomes for Children and Families
Home visiting programs are funded through both federal and state policies that regulate the use of evidence-based program models as well as implementation and evaluation procedures.12,13 Trained experts (such as nurses, para-professionals, or community residents) provide services in families’ homes targeting a range of family needs; providing case management; and promoting healthy nutrition, sensitive and responsive parenting, and child and parent physical and mental health.5 Although each program is distinct in its impact and some serve specific populations, taken together, MIECHV-funded home visiting services improve the quality of the home environment and increase confidence and competency in parenting skills.14 Programs also improve children’s school readiness skills and positively impact both child and maternal health indicators (e.g., increased number of child preventive care visits, fewer child emergency room visits, and reduced child maltreatment).15,16 Moreover, MIECHV-funded home visiting services have a return on investment of $1.80 to $5.70 for every dollar spent.4
Home Visiting Programs Effectively Pivoted to Virtual Service Delivery During the Pandemic
As the COVID-19 pandemic impacted families across the U.S., employment, child care, and family supports were widely disrupted. In turn, parent stress, caregiving challenges, and risk for child maltreatment increased.17 The need for home visiting services was great, yet social distancing practices impeded traditional service delivery. Federal and state legislatures increased flexibility in service reimbursement and evaluation requirements to support the shift to virtual services.11,18 In response, home visiting programs rapidly pivoted, developing strategies to maintain access to high-quality services through virtual modalities in order to support families in need.4,19 Strategies included helping families gain internet access and providing technology tutorials to families.20,21 Even prior to the pandemic, virtual services were viewed as a promising method for increasing family access, engagement, and participation in family and home visiting programs.22,23
Evaluations during the pandemic demonstrated that virtual home visiting programs could be effective and began to identify best practices for maintaining relationships and services through virtual modalities.24-26
- Throughout the transition to virtual delivery, programs maintained a high rate of service provision. Several programs found service provision indicators (e.g., maintenance of services, home visitor caseloads, family program completion rates) were close to or the same as pre-pandemic levels.27-29
- In one national program, home visitors aim to improve parenting by providing in-the-moment feedback about parenting behaviors known to support child development. Researchers found that home visitors were able to maintain high quality and frequent parenting feedback through virtual modalities.10
- Virtual home visiting also improved parental well-being, with families reporting declines in feelings of isolation, reduced personal and family stress, and improved access to medical care compared with families not enrolled in home visiting.7,8
- One study found that in just 10 weeks of virtual home visiting, parents became more responsive to their children’s play behaviors, an improvement similar to that found from in-person services.9
- Families and providers largely support retaining flexibility for virtual services as an option.5 A recent survey found that 68% of home visiting providers and 67% of parents agreed that virtual home visiting services should continue to be an option after the pandemic.30
Home Visiting Programs Continue to Face Challenges to Address the Diverse Needs of Families
Not all families are best served by the same home visiting program or modality.31 Although virtual visits have been found to be effective, they are not an effective modality for every family.32 Additionally, home visitors face their own challenges that can impact service provision.
- Home visitors may be less likely to reach families of color, low-income families, or families with several risk factors through virtual visits compared to pre-pandemic in-person programs.5,7
- Many families, including one in six families living in poverty, do not have reliable technology and internet access.23,33,34 In one home visiting program, providers reported that 21% of the families they serve do not have adequate data plans for virtual service delivery.6
- Personal challenges among home visiting providers during the pandemic (e.g., loss of child care, family or personal illness, low wages) also influenced service delivery.6,28,25 In a recent study, one quarter of the home visiting workforce reported symptoms of depression.28
Expand MIECHV Program Resources and Flexibilities to Help Providers Tailor Home Visiting Services to Individual Families
Home visiting is a critical service, and one that successfully pivoted to virtual programming during the pandemic, improving accessibility for some, albeit reducing access for others.6,20,24 Screening family preference and technology availability and supporting both in-person and virtual service delivery options could potentially increase accessibility, especially for marginalized, under-resourced populations.20
Other flexible innovations are also essential. Leading scientists in the field of early intervention support a precision approach to home visiting—that is, a focus on what works best for whom based on family needs, constraints, and program features and methods.31,36,37 Such a precision approach— for example, matching specific program components with individual family needs—could lead to more efficient and effective programs for families and children.31,37
Increasing funding for MIECHV programs, especially increased support for targeting higher risk communities, would help ensure that:
- Resources are allocated to facilitate appropriate services (e.g., technology and technology tutorials, child care or transportation support, workforce expansion efforts) to increase millions of families’ access to and engagement with home visiting programs.20,38
- Continued program evaluation expands evidence on newer virtual and precision approaches to best target home visiting service provision and effective implementation.20,31,37
- Resources better support home visiting providers’ mental health and well-being, and provide opportunities for acquisition of new professional skills to help retain this valuable workforce.28,35
(1) Avellar, S.A. & Supplee, L. (2013). Effectiveness of home visiting in improving child health and reducing child maltreatment. Pediatrics, 132 (Supplement 2), S90-S99. doi: 10.1542/peds.2013-1021G
(2) Minkovitz, C.S., O’Neill, K.M.G., & Duggan, A.K. (2016). Home visiting: A service strategy to reduce poverty and mitigate its consequences. Academic Pediatrics, 16(3), S105-S111. doi: 10.1016/j.acap.2016.01.005
(3) National Home Visiting Resource Center. (2021). 2021 Home Visiting Yearbook. James Bell Associates and the Urban Institute.
(4) O’Neill K., Korfmacher J., Zagaja, C., & Duggan A. (April, 2020). COVID19’s Early Impact on Home Visiting. First Report from a National HARC-Beat Survey of Local Home Visiting Programs. Home Visiting Applied Research Collaborative. https://www.hvresearch.org/wp-content/uploads/2020/04/COVID-19s-Early-Impact-on-Home-Visiting.pdf
(5) Traube, D.E., Palmer Molina, A., YingWangKay, S., & Kemner, A. (2022). Perinatal mental health support and early childhood home visitation during COVID-19. Prevention Science,23, 260-270. doi: 10.1007/s11121-021-01313-9
(6) Self-Brown, S., Reuben, K., Perry, E.W., Bullinger, L.R., Osborne, M.C., Bielecki, J., & Whitaker, D. (2020). The impact of COVID-19 on the delivery of an evidence-based child maltreatment prevention program: Understanding the perspectives of SafeCare® providers. Journal of Family Violence. doi: 10.1007/s10896-020-00217-6
(7) Rybińska, A., Best, D.L., Goodman, W.B. Weindling, W., & Dodge, K. (2022). Home visiting services during the COVID-19 pandemic: Program activity analysis for Family Connects. Maternal and Child Health Journal, 26, 70-78. doi: 10.1007/s10995-021-03337-7
(8) LeCroy & Milligan Associates, Inc. (2021). Parents as Teachers Randomized Control Trial: Interim Report, Years 1-3 (2019-2021). Tucson, AZ.
(9) Schein, S.S., Roben, C.K.P., Costello, A.H., & Dozier, M. (in press). Home visiting through telehealth during a pandemic: Transitioning to virtual visits with effectiveness. Child Maltreatment.
(10) Roben, C.K.P., Kipp, E., Schein, S.S., Costello, A.H., & Dozier, M. (2022). Unanticipated transitions to telehealth due to COVID-19: Maintaining model fidelity. Infant Mental Health Journal, 43(1), 173-184. doi: 10.1002/imhj.21963
(11) Home Visiting Coalition. (n.d.). MIECHV Reauthorization. Retrieved April, 2022. https://nationalhomevisitingcoalition.org/wp-content/uploads/MIECHV-Reauthorization-1-pager-1.pdf
(12) Maternal, Infant, and Early Childhood Home Visitation (MIECHV). (2020). Partnering with Parents to Help Children Succeed. https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/pdf/programbrief.pdf
(13) National Conference of State Legislatures (2021, May). Home visiting: Improving outcomes for children. NCSL. https://www.ncsl.org/research/human-services/home-visiting-improving-outcomes-for-children635399078.aspx
(14) Michalopoulos, C., Faucetta, K., Hill, C.J., Portilla, X.A., Burrell, L., Lee, H., Duggan, A., & Knox, V. (2019). Impacts on family outcomes of evidence-based early childhood home visiting: Results from the Mother and Infant Home Visiting Program Evaluation. OPRE Report 2019-07. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.
(15) Williams, K., Ruiz, F., Hernandez, F., & Hancock, M. (2020). Home visiting: A lifeline for families during the COVID-19 pandemic. Archives of Psychiatric Nursing, 35(1), 129-133. doi: 10.1016/j.apnu.2020.10.013
(16) Zaveri, H., Burwick, A., & Maher, E. (2014, March). Home Visiting: The potential for cost savings from home visiting due to reductions in child maltreatment. Casey Family Programs. https://www.casey.org/media/evidence-based-home-visiting.pdf
(17) Bullinger, L.R., Marcus, S., Reuben, K., Whitaker, D., & Self-Brown, S. (2022). Evaluating child maltreatment and family violence risk during the COVID-19 Pandemic: Using a telehealth home visiting program as a conduit to families. Infant Mental Health Journal, 43(1), 143-158. doi: 10.1002/imhj.21968
(18) Center for Medicaid and Medicare Services. (n.d.). State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth. Retrieved April, 2022. https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf
(19) Korfmacher, J., Molloy, P., Frese, M. (2021). Virtually the Same? Surveying Home Visitor Adaptations in Response to COVID-19. Research Brief prepared by Erikson Institute and the Home Visiting Applied Research Collaborative. https://www.erikson.edu/wp-content/uploads/2021/10/Research-Brief-1-HV-COVID-Survey.pdf
(20) Clary, E. (2021, August). Equity considerations for delivering human services virtually. Research Brief prepared by the Office of the Assistant Secretary for Planning and Evaluation and Mathematica. https://aspe.hhs.gov/sites/default/files/2021-08/vhs-equity-considerations.pdf
(21) Rapid Response - Virtual Home Visiting Collaborative. (2020). Observing, Listening & Understanding in a Virtual Environment [Webinar]. https://rrvhv.earlyimpactva.org/webinar/observing-listening-understanding-in-a-virtual-environment
(22) Guastaferro, K., Self-Brown, S., Shanley, J.R., Whitaker, D.J., & Lutzer, J.R. (2020). Engagement in home visiting: An overview of the problem and how a coalition of researchers worked to address this cross-model concern. Journal of Child and Family Studies, 29, 4-10.
(23) Hall, C.M. & Bierman, K.L. (2015). Technology-assisted interventions for parents of young children: Emerging practices, current research, and future directions. Early Childhood Research Quarterly, 33(4), 21-32. doi: 10.1016/j.escresq.2015.05.003
(24) Zero to Three (2020). States modify home visiting services in response to COVID-19. https://www.zerotothree.org/resources/3315-states-modify-home-visiting-services-in-response-to-covid-19
(25) Marshall, J., Kilström, L., Buro, A., Chandran, V., Prieto, C., Stein-Elger, R., Koeut-Futch, K., Parish, A., & Hood, K. (2020). Statewide implementation of virtual perinatal home visiting during COVID-19. Maternal and Child Health Journal, 24, 1223-1230. doi: 10.1007/s10995-020-02982-8
(26) National Alliance of Home Visiting Models (2020, March 25). Model guidance in response to COVID-19. https://cppr-institute-prod.s3.amazonaws.com/modules/resources/web/crr/resources/Alliance-Guidance.pdf
(27) Rybińska, A., Best, D.L., Goodman, W.B. Bai, Y., & Dodge, K. (2022). Transitioning to virtual interaction during the COVID-19 pandemic: Impact on the Family Connects postpartum home visiting program activity. Infant Mental Health Journal, 43(1), 159-172. doi: 10.1002/imhj.21953
(28) Child Trends (2020). Findings from the First 5 California Home Visiting Workforce Study. https://www.childtrends.org/publications/findings-from-the-first-5-california-home-visiting-workforce-study
(29) Bock, M.J., Kakavand, K., Carega, D., & Gozalians, S. (2021). Shifting from in-person to virtual home visiting in Los Angeles County: Impact on programmatic outcomes. Maternal and Child Health Journal, 25(7), 1025-1030. doi: 10.1007/s10995-021-03169-5
(30) Chazan-Cohen, R., Fisk, E., Ginsberg, I., Gordon, A., Green, B. L., Kappesser, K., Lau, S., Ordonez-Rojas, D., Perry, D.F., Reid, D., Rodriguez, L., & Tomkunas, A. (2021, September). Parents' Experiences with Remote Home Visiting and Infant Mental Health Programs During COVID-19: Important Lessons for Future Service Delivery. Report submitted to the Perigee Fund, Seattle WA.
(31) Home Visiting Applied Research Collaborative. (2020, February 5). Introduction to precision home visiting. https://www.hvresearch.org/precision-home-visiting/introduction-to-precision-home-visiting/
(32) Korfmacher, J., Molloy, P., & Frese, M. (2021). “But it’s not the same”: What happens in virtual home visits? Research Brief prepared by Erikson Institute and the Home Visiting Applied Research Collaborative. https://www.erikson.edu/research/optimizing-reach-engagement-and-effectiveness-of-interactive-video- conferencing-ivc-visits/
(33) Racine, N., Hartwick, C., Collin-Vézina, D., &Madigan, S. (2020). Telemental health for child trauma treatment during and post-COVID-19: Limitations and considerations. Child Abuse & Neglect, 110. doi: 10.1016/j.chiabu.2020.104698
(34) Swenson, K. & Ghertner, R. (2020). People in low-income households have less access to internet services. Research brief prepared by the Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health & Human Services. https://aspe.hhs.gov/sites/default/files/private/pdf/263601/Internet_Access_Among_Low_Income.pdf
(35) Fitzgerald Lewis, E., Voelker, S., Rudick, S., Fields, E., & Elliott, K. (2020). Recruitment and Retention of Home Visitors. Home Visiting Impacts & Insights Brief Series, 1(1). Waltham, MA: EDC.
(36) Center on the Developing Child at Harvard University. (2016). From best practices to breakthrough impacts: A science-based approach to building a more promising future for young children and families. Cambridge, MA. Retrieved from: https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2016/05/From_Best_Practices_to_Breakthrough_Impacts-4.pdf
(37) O’Neill K, West A, Burrell L, Poes M, Spinosa CZ, Chute D, and Duggan A. (2022). Using the Precision Paradigm in State-Led Evaluations. http://www.hvresearch.org/wp-content/uploads/2022/04/HARC-Resource-on-PHV-for-CSE-Awardees.pdf
(38) Prenatal-to-3 Policy Impact Center: Research for action and outcomes. (n.d.) Evidence-based home visiting programs. Retrieved April, 2022. https://pn3policy.org/pn-3-state-policy-roadmap-2021/us/home-visiting/