Waves of Change in Home Visiting:Transforming Practice, Maximizing Impacts

Deborah Daro

Main Points

• Interest in home visiting is the logical consequences of 40 years of investing in early childhood to maximize our human capital.

• The AIA grantees offer the EBHV home visiting field important learning opportunities for extending the impacts of state and Federal investments in the model.

• The AIA and MIECHV efforts face similar challenges in– Developing a competent and effective work force– Replicating programs with fidelity while creating innovation– Building integrated systems of care

The Evolution of Home Visiting

Past and Potential Future of Home Visiting

• Wave 1: Gradual recognition of home visiting as a unique and powerful service strategy.

• Wave 2: Extensive testing and replication of multiple national home visiting models.

• Wave 3: Achieving national recognition and securing Federal investment.

• Wave 4: Successfully using home visiting as leverage to secure sustainable change.

Promising Characteristics of Home Visiting

• Provide services in a participant’s home, reducing the barriers to engagement.

• Allows one to target and shape the intervention to the needs of each specific family.

• Facilitates contact with other family members and care providers.

• Models “relationship building”.

Factors Supporting Home Visiting Expansion• Convergence of political interests, clinical

knowledge and empirical research.• Success of home visitation efforts in achieving

positive outcomes – there is evidence the strategy works.

• Hawaii’s statewide expansion of Healthy Start – there is evidence you can do this to scale.

• Offered promise of greater reach.

Documented Outcomes of Home Visiting

Initiated During Pregnancy/Birth– Better birth outcomes (if offered during pregnancy)– Enhanced parent-child interactions– Positive maternal life and health choices– More efficient use of health care and community services– Enhanced child development and early detection of

developmental delaysToddlers

– Early literacy skills– Social competence– Parent involvement in learning

Initial State Investments in Home Visiting

• National HV models grew rapidly between 1990 – 2010 -- serving 400,000 to 500,000 families.

• Specific State-level investment– 40 states provided a total of 70 different home visitation

models to local residents.– 34 states engaged in interagency planning around the

model and 15 states have established tiered systems to serve high and low risk parents.

– Total expenditures in these models exceed $250 million by 2010.

Maternal, Infant, Early Childhood Home Visiting • Goal

– Included in the 2010 Affordable Care Act– Assists states in building a comprehensive early childhood system

to promote the health and safety of pregnant women, children 0-8 and their families

• Investments– $1.5 billion allocated to states FY 10 to FY14 on a formula and

competitive basis– $11.2 million for Technical Assistance– $27 million for a national evaluation, focused primarily on

documenting participant outcomes

MIECHV Opportunities• Creates a structure for interagency collaboration

and a new type of public-private partnership.• Promotes higher quality practice across all

agencies and interventions.• Promotes resource and coalition building at the

community level.• Raises the national profile of the importance of a

child’s first five years of life.

MIECHV Challenges

• Insufficient resources to achieve the initiative’s immediate and aspirational objectives.

• Cumbersome regulations and significant data demands on all stakeholders.

• A time frame that fails to account for the slow pace of change and complex local regulations.

• The lack of a coherent decision making framework to manage all diverse interests.

AIA’s Key Contributions to Field Building

• Knowledge on how to identify and engage important high risk populations.

• Knowledge on how to integrate mental health services within the context of home based interventions.

• Strategies to create effective policy and practice linkages with child welfare, substance abuse, and justice systems.

Shared Opportunities for Learning

• How to train and empower the home visiting workforce to bring added value and innovation to program development.

• How to balance the equally important tasks of replicating with fidelity and developing innovations.

• How to capture the concept of “collective impact” in building effective service partnerships.

Elevating Workforce Quality and Consistency

Why are the best programs working?

• Theoretical integrity and focused content.• Focusing intervention efforts on the earliest stages of the

developmental process.• Employing persistent, but respectful, outreach methods to

engage multi-problem families.• Systematically assessing the needs of the target population

across a number of domains that impact relevant risk and protective factors.

• Providing participants access to a core body of knowledge and skills and facilitating access to other community resources as needed.

Key Elements for an Effective Work Force

• The ability to bring added value to any task.– Identify opportunities to enhance the service experience.– Balance the need for fidelity with the potential for innovation.

• A robust knowledge base in key areas and a “curiosity” to learn more.

• A skilled “relationship builder” who connects with both program participants and colleagues.

• A commitment to cultural humility.– Move from mastering a body of knowledge to sustaining an

ongoing commitment to learning and understanding.

Strategies To Strengthen Workforce Capacity• Self-generating peer learning opportunities across home

visitors, supervisors and agency managers.• State/county training centers

– To support initial model implementation– To provide ongoing staff development opportunities– To support core competencies and service components.

• Annual state meetings/conferences for all home visiting program providers and others serving young children and their families.

Balancing FidelityAnd

Creating Innovation

The Dilemma

• Maximizing population level change requires that promising interventions and policies be taken to scale with fidelity.

• Extending a program’s “reach” often requires adaptation and modification to meet the needs of emerging populations and changing conditions.

• Such adjustments, if not carefully done, can and does reduce a program’s impacts.

Common Barriers to Quality Expansion• Lack of internal organizational capacity• Lack of guidelines regarding innovation or model adaptation• “Gravitational pull”

Factors Facilitating Quality Replication

• Careful selection of replication sites.• Clear implementation guidelines and compliance

indicators.• Strong initial training, ongoing coaching and a

process for early monitoring of key practice principles.

• Time sensitive management information systems and feedback on participant outcomes.

Quality Program Improvement Cycle

ImprovedParticipantOutcomes

tEnhanced

ProviderPerformance/Leadership

Supportive Organizational/Agency Culture

Replicatingwith

Fidelity

Barriers to Quality Expansion

Limited organizational capacityRigid adherence to model

Untested modifications to core practice“Gravitational Pull”

Facilitators of Quality Expansion

Relevant Content/CurriculumReflective practice

Collaborative planning

Careful supervision and monitoring

An Integrated Vision:Elevate the Mission and Plan for

Systemic Change

IntegratedData Systems/CommonMeasures

Shared Activities

AndFunctions

CommonVision/Shared

Outcomes

Multi-AgencyCollaborative

Chapin Hall

Building “Collective Impact”• Establish a common agenda that moves the mission

outside any specific agency “silo”.• Obtain agreement among partners on:

– Time horizon – when do you want to see change.– Risk – tolerance for innovation and new practice.– Scope – size of the target population/geographic area.

• Agree on a shared definition of “success”– Establish benchmarks and develop a system to monitor progress

toward objectives across all investments.– Use data to understand the present and plan for the future.

Kania & Kramer, 2011. Collective impact. Stanford Social Innovation Review, (Winter), 36-41.

Building “Collective Impact”• Identify mutually reinforcing activities (positive “spill-over”

effects)– Determine appropriate balance between infrastructure and

programmatic investments– Encourage ownership of a new idea or reform through active

participation in decision making– Understand the value in collective action and shared resources

and act in ways that build interdependence

• Foster continuous communication and feedback loops• Create a new, independent “backbone” organization or

service program to link elements together

Kania & Kramer, 2011. Collective impact. Stanford Social Innovation Review, (Winter), 36-41.

Redefining The Benchmarks for Success• Set benchmarks for direct services at the population level

not simply for those receiving services– Improving child and maternal health– Preventing injury, maltreatment and violence– Improve school readiness– Improve family self-sufficiency

• Establish specific benchmarks to track system change– Document efficiencies in agency operations– Document interagency activities– Track shifts in the source and level of all investments

Staying the Course

The Great Society asks not how much, but how good; not only how to create wealth but how to use it; not only how fast we are going, but where we are headed.

It proposes as the first test for a nation: the quality of its people.This kind of society will not flower spontaneously from swelling riches

and surging power.It will not be the gift of government or the creation of presidents. It

will require of every American, for many generations, both faith in the destination and the fortitude to make the journey.

And like freedom itself, it will always be challenge and not fulfillment.LBJ (1965)