Home Visiting:

A Promising Early Intervention Strategy for At-Risk Families

HRD-90-83: Published: Jul 11, 1990. Publicly Released: Jul 16, 1990.

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Pursuant to a congressional request, GAO reviewed home visiting, focusing on: (1) the nature and scope of home-visiting programs in the United States and Europe; (2) its effectiveness; (3) strategies critical to the design of programs that use home visiting; and (4) federal options in using home visiting.

GAO found that: (1) some programs using home visiting improved the health and well being of families and children; (2) home visiting reduced the need for more costly services, but minimal research has compared its cost-effectiveness to other early intervention strategies; (3) some programs using home visiting failed to meet their objectives, primarily due to fundamental program design and operation problems; (4) successful programs usually combined home visiting with center-based and other community services adapted to their target group's needs; (5) the Department of Health and Human Services (HHS) and the Department of Education support home visiting through both one-time demonstration projects and ongoing funding sources, but are not coordinating and focusing their efforts; (6) Congress focused its home-visiting interest on maternal and child health initiatives, and considered legislation amending Medicaid to explicitly service pregnant women and infants, but did not pass the proposed legislation; (7) the legislation would have caused additional Medicaid costs, ranging from $95 million for optional home-visiting services to $625 million for mandatory services from fiscal years 1990 through 1994; and (8) the federal government could strengthen program design and operation for home visiting by communicating the knowledge developed at the federal, state, and local levels.

Matter for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: H.R. 290, H.R. 1391, and S. 902 were introduced with a provision to make home visiting an optional covered Medicaid service for high-risk women and infants. Congress enacted a home-visiting program in P.L. 102-321. The Committee cited the GAO report and recommended using the report's program design elements as criteria to choose grantees. No further action has been taken regarding provisions to make home visiting an allowable Medicaid service and no future action, according to HHS officials and other experts, is expected. The reason cited is anticipated changes to Medicaid as a result of health care reform.

    Matter: Congress has expressed its interest in home visiting as a strategy for bolstering at-risk families. In view of the demonstrated benefits and cost savings associated with home visiting, Congress should consider establishing a new optional Medicaid benefit: as prescribed by a physician or other Medicaid-qualified provider, prenatal and postpartum home-visiting services for high-risk women, and home-visiting services for high-risk infants at least up to age 1. Making home visiting an explicitly covered Medicaid service to improve birth outcomes will encourage states to provide ongoing funding for prenatal and postpartum home visiting.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: Education agreed and has incorporated language on objectives in requests for proposals.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate clear objectives, which are used to manage program progress and to evaluate program outcomes.

    Agency Affected: Department of Education

  2. Status: Closed - Implemented

    Comments: HHS has required a "clear statement of the problem" and "measurable goals and objectives" in home-visiting projects funded through the new Maternal and Child Health (MCH) Block grant set-aside.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate clear objectives, which are used to manage program progress and to evaluate program outcomes.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: Education agreed and is using similar requirements.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate structured services by trained and supervised home visitors whose skills match the services they deliver.

    Agency Affected: Department of Education

  4. Status: Closed - Implemented

    Comments: HHS has required planned services delivered by qualified personnel supervised by appropriate health personnel in new home-visiting projects authorized under the MCH block grant set-aside.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate structured services by trained and supervised home visitors whose skills match the services they deliver.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Implemented

    Comments: OSEP recommended establishing close linkages to project directors at their annual meeting, but has not required it for previous requests for proposals from home-visiting projects.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate close linkages to other service organizations to facilitate access to needed services.

    Agency Affected: Department of Education

  6. Status: Closed - Implemented

    Comments: HHS has required case management and linkage into the existing service delivery system for new home-visiting projects funded under the MCH block grant set-aside.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate close linkages to other service organizations to facilitate access to needed services.

    Agency Affected: Department of Health and Human Services

  7. Status: Closed - Implemented

    Comments: Education agrees and uses this approach in its outreach program.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate commitments for further funding beyond any federal demonstration period to sustain benefits beyond short-term initiatives.

    Agency Affected: Department of Education

  8. Status: Closed - Implemented

    Comments: As it has previously, HHS has encouraged MCH projects to plan how to continue funding if and when federal funding is discontinued.

    Recommendation: The Secretaries of Health and Human Services and Education should require federally funded programs that use home visiting to incorporate commitments for further funding beyond any federal demonstration period to sustain benefits beyond short-term initiatives.

    Agency Affected: Department of Health and Human Services

  9. Status: Closed - Implemented

    Comments: HHS language in the draft case for proposals indicates compliance with the recommendation.

    Recommendation: The Secretary of Health and Human Services should incorporate those program design components when implementing provisions of the Omnibus Budget Reconciliation Act of 1989 pertaining to new home-visiting demonstration projects.

    Agency Affected: Department of Health and Human Services

  10. Status: Closed - Implemented

    Comments: Education provided information on home visiting for dissemination through the National Information Center on Handicapped Children and Youth and at regional resource centers.

    Recommendation: The Secretaries of Health and Human Services and Education should make existing materials on home visiting more widely available through established clearinghouses, conferences, and communications with states and grantees.

    Agency Affected: Department of Education

  11. Status: Closed - Implemented

    Comments: HHS requested its technical providers to disseminate materials on home visiting to state agencies and other interested parties.

    Recommendation: The Secretaries of Health and Human Services and Education should make existing materials on home visiting more widely available through established clearinghouses, conferences, and communications with states and grantees.

    Agency Affected: Department of Health and Human Services

  12. Status: Closed - Implemented

    Comments: OSEP disseminated a report on comparative costs and benefits of home- and center-based services for handicapped children. OSEP also provided technical support to the project.

    Recommendation: The Secretaries of Health and Human Services and Education should provide technical or other assistance to programs to more systematically evaluate the costs, benefits, and future cost savings associated with home-visiting services.

    Agency Affected: Department of Education

  13. Status: Closed - Implemented

    Comments: HHS is encouraging and funding cost-effectiveness evaluations of home visiting and will continue to disseminate the results through existing clearinghouses and technical assistance projects.

    Recommendation: The Secretaries of Health and Human Services and Education should provide technical or other assistance to programs to more systematically evaluate the costs, benefits, and future cost savings associated with home-visiting services.

    Agency Affected: Department of Health and Human Services

  14. Status: Closed - Implemented

    Comments: Education reviewed its support of projects and continues to support home-visiting projects so that the special home-visiting initiative is contemplated.

    Recommendation: The Secretaries of Health and Human Services and Education should give priority to collaborative, interagency demonstration projects designed to: (1) meet the multiple needs of target populations; (2) incorporate home visiting permanently into local maternal and child health and welfare service systems; and (3) replicate models that have demonstrated their efficacy.

    Agency Affected: Department of Education

  15. Status: Closed - Implemented

    Comments: HHS agreed to give priority to collaborative, interagency demonstration projects.

    Recommendation: The Secretaries of Health and Human Services and Education should give priority to collaborative, interagency demonstration projects designed to: (1) meet the multiple needs of target populations; (2) incorporate home visiting permanently into local maternal and child health and welfare service systems; and (3) replicate models that have demonstrated their efficacy.

    Agency Affected: Department of Health and Human Services

  16. Status: Closed - Implemented

    Comments: FICC did not agree this was an appropriate role for it and declined the role.

    Recommendation: The Secretaries of Health and Human Services and Education should charge the Federal Interagency Coordinating Council with the federal leadership role in coordinating and assisting home-visiting initiatives through such activities as: (1) providing technical assistance in developing program services and program evaluations; and (2) supporting the development of a core curriculum for home-visitor training.

    Agency Affected: Department of Education

  17. Status: Closed - Implemented

    Comments: FICC did not agree that this was an appropriate role for it and declined it.

    Recommendation: The Secretaries of Health and Human Services and Education should charge the Federal Interagency Coordinating Council with the federal leadership role in coordinating and assisting home-visiting initiatives through such activities as: (1) providing technical assistance in developing program services and program evaluations; and (2) supporting the development of a core curriculum for home-visitor training.

    Agency Affected: Department of Health and Human Services

 

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