United States General Accounting Office ___________________________________________________________________ GAO Report to the Chairman, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, Committee on Appropriations U.S. Senate ___________________________________________________________________ July 1990 HOME VISITING A Promising Early Intervention Strategy for At-Risk Families Some of the information in this report--e.g., pictures, charts, and tables--was not in ASCII text format and not included. If you wish to obtain a complete report, call GAO report distribution at 202/275-6241 (7:30 a.m.-5:30 p.m. EST) or write to GAO, P.O. Box 6015, Gaithersburg, MD 20877. __________________________________________________________________ GAO/HRD-90-83 This U.S. General Accounting Office (GAO) report is 1 of 7 available over the Internet as part of a test to determine whether there is sufficient interest within this community to warrant making all GAO reports available over the Internet. The file REPORTS at NIH lists the 7 reports. So that we can keep a count of report recipients, and your reaction, please send an E-Mail message to KH3@CU.NIH.GOV and include, along with your E-Mail address, the following information: 1) Your organization. 2) Your position/title and name (optional). 3) The title/report number of the above reports you have retrieved electronically or ordered by mail or phone. 4) Whether you have ever obtained a GAO report before. 5) Whether you have copied a report onto another bulletin board--if so, which report and bulletin board. 6) Other GAO report subjects you would be interested in. GAO's reports cover a broad range of subjects such as major weapons systems, energy, financial institutions, and pollution control. 7) Any additional comments or suggestions. Thank you for your time. Sincerely, Jack L. Brock, Jr. Director, Government Information and Financial Management Issues Information Management and Technology Division B-238394 July 11, 1990 The Honorable Tom Harkin Chairman, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies Committee on Appropriations United States Senate Dear Mr. Chairman: This report, prepared at the Subcommittee's request, reviews home visiting as an early intervention strategy to provide health, social, educational, or other services to improve maternal and child health and well-being. The report describes (1) the nature and scope of existing home-visiting programs in the United States and Europe, (2) the effectiveness of home visiting, (3) strategies critical to the design of programs that use home visiting, and (4) federal options in using home visiting. This report contains a matter for consideration by the Congress and recommendations to the Secretaries of Health and Human Services and Education. As agreed with your office, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days from the date of this letter. At that time, we will send copies to the Secretaries of Health and Human Services and Education and to interested parties and make copies available to others upon request. This report was prepared under the direction of Linda G. Morra, Director, Intergovernmental and Management Issues, who may be reached on 275-1655 if you or your staff have any questions. Other major contributors to this report are listed in appendix V. Sincerely yours, Charles A. Bowsher Comptroller General of the United States 1 EXECUTIVE SUMMARY ----------------- PURPOSE ------- Families that are poor, uneducated, or headed by teenage parents often face barriers to getting the health care or social support services they need. Many experts believe that an effective way to reduce barriers is to deliver such services directly in the home. This is known as home visiting. They also believe that using home visiting to deliver or improve access to early intervention services--prenatal counseling, parenting instruction for young mothers, and preschool education--can address problems before they become irreversible or extremely costly. Is home visiting an effective service delivery strategy? What are the characteristics of programs that use home visiting? Are there opportunities to expand the use of home visiting? The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies asked GAO to answer these questions. BACKGROUND ---------- Home visitors have worked with families in the United States and Europe for more than 100 years. In-home services began when public health officials recognized that proper prenatal and infant care could reduce infant deaths. Home visitors provide a variety of services--prenatal visits, health education, parenting education, home-based preschool, and referrals to other agencies and services. While home visiting can also be used to deliver services to the chronically ill and the elderly, this report focuses on delivering early intervention services to at-risk families with young children. For this study, GAO reviewed the home-visiting literature; interviewed international, federal, state, and local program officials and other experts in medical, social, and educational service delivery; and reviewed eight programs in the United States, Great Britain, and Denmark that used home visiting. RESULTS IN BRIEF ---------------- Home visiting is a promising strategy for delivering or improving access to early intervention services that can help at-risk families become healthier and more self-sufficient. Evaluations have demonstrated that such services are particularly useful when families both face barriers to needed services and are at risk of such poor outcomes as low birthweight, child abuse and neglect, school failure, and welfare dependency. While few cost studies of home visiting have been done, they have shown that 2 delivering preventive services through home visiting can reduce later serious and costly problems. But the cost-effectiveness of home visiting, compared to other strategies to provide early intervention services, has not been well researched. Not all programs that use home visiting have met their objectives. Success depends on a program's design and operation. Well-designed programs share several critical components that enhance their chances of success. Home visiting does not stand alone; much of its success stems from connecting clients to a wider array of community services. The federal government's home-visiting activities can be better coordinated and focused. The Departments of Health and Human Services (HHS) and Education provide funding for various home- visiting services and initiatives. But the knowledge gained through these efforts is not always shared across agencies and with state and local programs. The federal government is uniquely situated to strengthen program design and operation for home visiting by communicating the wealth of practical knowledge developed at the federal, state, and local levels. GAO'S ANALYSIS -------------- Home Visiting Can Be an Effective Service Delivery Strategy ----------------------------------------------------------- Evaluations of early intervention programs using home visiting demonstrate that these programs can improve both the short- and long-term health and well-being of families and children. Compared to families who were not given these services, home- visited clients had fewer low birthweight babies and reported cases of child abuse and neglect, higher rates of child immunizations, and more age-appropriate child development. Evaluations of home visiting that examined costs have demonstrated its potential to reduce the need for more costly services, such as neonatal intensive care. However, few experimental research initiatives have compared the cost- effectiveness of home visiting to that of other early intervention strategies. Successful programs usually combined home visiting with center- based and other community services adapted to the needs of their target group. Longitudinal studies showed that visited families showed lasting positive effects, including less welfare dependency. Characteristics That Strengthen Program Design and Implementation ----------------------------------------------------------------- Although many early intervention programs using home visiting have succeeded, others have failed to meet their stated objectives. Evaluators have attributed such failures to fundamental problems with program design and operation. GAO 3 identified critical design components for developing and managing programs using home visiting that include (1) developing clear objectives and focusing and managing the program in accordance with these objectives; (2) planning service delivery carefully, matching the home visitor's skills and abilities to the services provided; (3) working through an agency with a capacity to deliver or arrange for a wide range of services; and (4) developing strategies for secure funding over time. Federal Commitment Can Be Better Coordinated and Focused -------------------------------------------------------- HHS and Education support home visiting through both one-time demonstration projects and ongoing funding sources, such as Medicaid (a federal-state medical assistance program for needy people). But federal managers were not always aware of results in other agencies, materials developed through federally funded efforts, or state and local home-visiting efforts. The Federal Interagency Coordinating Council is a multiagency body that attempts to mobilize and focus federal efforts on behalf of handicapped children or those at risk of certain handicapping conditions. The Council is one federal mechanism that can be used to better disseminate information on successful home-visiting efforts and encourage collaboration on joint agency projects. Federal demonstration projects could be better focused to improve program design and fill information voids. Federal managers should emphasize evaluating potential cost savings associated with programs using home visiting and developing strategies to *better integrate home visiting into community services, especially beyond federal demonstration periods. The Congress' recent interest in home visiting has focused on maternal and child health initiatives, including newly authorizing home-visiting demonstration projects through the Maternal and Child Health block grant. The Congress considered (but did not pass) legislation to amend the Medicaid statute to explicitly cover physician-prescribed home-visiting services for pregnant women and infants up to age 1. The Congressional Budget Office estimated that the additional federal fiscal year 1990-94 Medicaid costs for this initiative would range from $95 million, if home visiting were made an optional Medicaid service, to $625 million, if mandatory. MATTER FOR CONGRESSIONAL CONSIDERATION -------------------------------------- In view of the demonstrated benefits and cost savings associated with home visiting as a strategy for providing early intervention services to improve maternal and child health, the Congress should consider amending title XIX of the Social Security Act to 4 explicitly establish as an optional Medicaid service, where prescribed by a physician or other Medicaid-qualified provider, (1) prenatal and postnatal home-visiting services for high-risk women and (2) home-visiting services for high-risk infants at least up to age 1. RECOMMENDATIONS --------------- GAO recommends that the Secretaries of HHS and Education require federally supported programs that use home visiting to incorporate certain critical program design components for developing and managing home-visiting services. The Secretary of HHS should specifically incorporate these components into the Maternal and Child Health block grant home-visiting demonstration projects. GAO further recommends that the Secretaries -- make existing materials on home visiting more widely available through established mechanisms, such as agency clearinghouses, -- provide technical or other assistance to more systematically evaluate the costs, benefits, and potential cost savings associated with home-visiting services, and -- charge the Federal Interagency Coordinating Council with the federal leadership role in coordinating and assisting home- visiting initiatives. AGENCY COMMENTS --------------- HHS and the Department of Education generally concurred with GAO's conclusions and recommendations. Both agreed with the need for more research and evaluation of the costs and benefits of home visiting. Without such data, they expressed reluctance to give priority to home visiting over other early intervention service delivery strategies. Education supported the Council as a focal point for federal home-visiting activities, although HHS believed it to be beyond the scope of the Council's mission. In regard to establishing home visiting as an optional Medicaid service, HHS stated that states essentially have the option now to cover home visiting under a variety of Medicaid categories of service. GAO believes, however, that amending the Medicaid statute to explicitly cover home visiting as an optional service would send a clear message to states about the efficacy of home visiting, especially for high-risk pregnant women and infants. 5 CONTENTS -------- Page ---- LETTER 1 EXECUTIVE SUMMARY 2 CHAPTER 1 INTRODUCTION 10 What Is Home Visiting? 10 Some Families Face Service Barriers 11 Home Visiting as an Early Intervention 13 Strategy Objectives, Scope, and Methodology 15 CHAPTER 2 HOME VISITING IS AN ESTABLISHED SERVICE 17 DELIVERY STRATEGY WITH MULTIPLE OBJECTIVES Home Visiting Widespread in Europe 17 U.S. Home Visiting Targeted to Low-Income 19 and Special Needs Families Funding for U.S. Home Visiting From 21 Multiple Agencies New Impetus for Home Visiting From Recent 24 Legislation CHAPTER 3 HOME-VISITING EVALUATIONS DEMONSTRATE 30 BENEFITS, BUT SOME QUESTIONS REMAIN Program Evaluations Show Benefits 30 of Home Visiting Research Shows Home Visiting Compared to 37 Other Strategies Promising, but More Study Is Needed Limited Research Shows Home Visiting 38 Can Produce Cost Savings CHAPTER 4 POOR PROGRAM DESIGN CAN LIMIT 42 BENEFITS OF HOME VISITING Poor Program Outcomes Linked to 42 Design Weaknesses 6 Critical Components for Program 46 Design CHAPTER 5 A FRAMEWORK FOR DESIGNING PROGRAMS 47 THAT USE HOME VISITING Clear Objectives as a Cornerstone 49 Structured Program Delivered by Skilled 52 Home Visitors Strong Community Ties in a Supportive 55 Agency Ongoing Funding for Program Permanency 58 CHAPTER 6 CONCLUSIONS, RECOMMENDATIONS, AND AGENCY 62 COMMENTS Conclusions 62 Matter for Congressional Consideration 66 Recommendations 66 Agency Comments 67 APPENDIXES APPENDIX I: Description of the Eight Home-Visiting 70 Programs GAO Visited APPENDIX II: What Happens on a Home Visit? 102 APPENDIX III: Comments from the Department of Education 106 (Could not be reproduced for electronic viewing) APPENDIX IV: Comments From the Department of Health and 107 Human Services (Could not be reproduced for electronic viewing) APPENDIX V: Major Contributors to this Report 108 TABLES TABLE 1.1: Early Intervention Saves Money 14 TABLE 2.1: Home Visiting in Nine Western 18 European Countries 7 TABLE 2.2: Federal Programs Used to Fund Home 22 Visitor Projects TABLE 2.3: Signatories to the FICC Memorandum of 26 Understanding TABLE 5.1: Characteristics of United States and 48 European Programs GAO Visited TABLE I.1 Program Profile: Center for Development, 71 Education, and Nutrition (CEDEN) TABLE I.2 Program Profile: Resource Mothers for 75 Pregnant Teens TABLE I.3 Program Profile: Roseland/Altgeld Adolescent 79 Parent Project (RAPP) TABLE I.4 Program Profile: Southern Seven Health 83 Department Program (Parents Too Soon and the Ounce of Prevention Components) TABLE I.5 Program Profile: Maternal and Child Health 87 Advocate Program TABLE I.6 Program Profile: Changing the Configuration 90 of Early Prenatal Care (EPIC) TABLE I.7 Program Profile: Great Britain's Health 94 Visitor Program TABLE I.8 Program Profile: Denmark's Infant Health 98 Visitor Program FIGURES (Could not be reproduced for electronic viewing.) FIGURE 1.1 Examples of Programs Using Home Visiting 11 to Serve At-Risk Families FIGURE 3.1: Students Receiving Preschool and Home Visiting 34 Services Were More Successful in Later Years FIGURE 3.2: Type and Amount of Services Affect Later 36 Reading Ability FIGURE 5.1 Framework for Designing Home Visitor 49 Services 8 ABBREVIATIONS ------------- AFDC Aid to Families With Dependent Children CEDEN Center for Development, Education and Nutrition EPIC Changing the Configuration of Early Prenatal Care FICC Federal Interagency Coordinating Council GAO General Accounting Office HHS Department of Health and Human Services MCH Maternal and Child Health PTS Parents Too Soon RAPP Roseland/Altgeld Adolescent Parents Program SPRANS Special Projects of Regional and National Significance VISTA Volunteers in Service to America VNA Visiting Nurses Association, Incorporated WIC Special Supplemental Food Program for Women, Infants, and Children 9 CHAPTER 1 --------- INTRODUCTION ------------ For more than a century in both the United States and Europe, home visitors have provided individuals and families with preventive and supportive health and social services directly in their homes. While not a new concept, home visiting is an evolving service delivery strategy that numerous agencies in the United States are embracing with renewed enthusiasm, for both humanitarian and economic reasons. Experts believe that intervening early in the lives of certain families at risk of such negative outcomes as low birthweight, child abuse, and educational failure offers them promise of a better future through improved health and education. They also believe that home visiting can break down barriers that prevent families from accessing the care they need and that preventive services can be less costly in the long run than providing more expensive crisis, curative, and remedial services. But what can home visiting do for those families facing many interconnected health, social, and educational risks? Is it an effective strategy for delivering services? What can we learn from the experience of Europe, where home visiting is a universal service? The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, in its search for innovative strategies to reduce threats to the health and well-being of disadvantaged families, asked us to answer these questions. WHAT IS HOME VISITING? ---------------------- Home visiting is a strategy that delivers health, social support, or educational services directly to individuals in their homes. Programs use home visitors of various disciplines and skills to accomplish various goals and provide various services. For example, home visiting has been used to deliver nutritional support to the elderly, medical care to the chronically ill, and social support to at-risk families. This report focuses on the home-based services, such as coaching, counseling, teaching, and referrals to other service providers for additional services, that are offered as a part of early intervention services for at- risk families with young children. Programs designed for such purposes can vary in their goals and services, as shown in figure 1.1. 10 Figure 1.1: Examples of Programs Using Home Visiting To Serve At-Risk Families Goals: Improved parenting skills Enhanced child development Improved birth outcomes Services: Information delivery Referrals to other service providers Emotional support Health care Providers: Nurses Paraprofessionals Teachers Social workers Home visiting occurs as a delivery strategy in three basic forms. The first is universal, in which all members of a broad population receive services. Great Britain uses public health nurses to provide preventive health information and examinations directly in the home to all families with newborns, regardless of family income status or need. The other two strategies target services to certain families. One offers a limited number of home visits to assess the environment and family situation, to provide some basic information, to reinforce positive behaviors, or to refer the family to other services as needed. The other targets some families for more intensive services, providing more frequent home visits over 1 or more years. Home visits may be part of other program services, which can include center-based parenting classes and job training classes, and developmental day care or preschool for children. SOME FAMILIES FACE SERVICE BARRIERS ----------------------------------- At-risk families, especially those who are poor, uneducated, or headed by teenage parents, often face barriers to getting the health, education, and social services they need. The barriers can be financial, structural, or personal. Some experts believe that home visiting can reduce barriers by providing needed services to these families. Lack of health insurance, the chief financial barrier, prevents many at-risk individuals from receiving adequate health care. An estimated 26 percent of the women of reproductive age--14.6 million--have no health insurance to cover maternity care, and two-thirds of these--9.5 million--have no health insurance at all. We reported in 1987#1 that Medicaid#2 recipients and 1Prenatal Care: Medicaid Recipients and Uninsured Women Obtain Insufficient Care (GAO/HRD-87-137, Sept. 30, 1987). 11 uninsured women received later and less sufficient prenatal care than privately insured women from the same communities. Women with no insurance must depend on free or reduced-cost care from a diminishing number of willing private physicians or from health department clinics and other settings usually financed by public funds. Limited community resources, such as numbers of hospitals, community health clinics, social service agencies, and individual providers able or willing to serve the at-risk population, create structural barriers to care. The Institute of Medicine has reported that the capacity of clinic systems used by the at-risk prenatal population is so limited that critically important care is not always available.#3 Affordable, quality child care for disadvantaged families is not keeping pace with the growing numbers of single-parent households. The child welfare system is hard-pressed to process the large number of children who now need protection. Inadequate funding for social and medical support programs presents an additional structural barrier to the disadvantaged. Only half of all poor children are covered by Medicaid. Fewer than half of the 7.5 million individuals eligible for the Special Supplemental Food Program for Women, Infants, and Children (WIC) receive the program's nutritional support. Head Start reaches only 20 percent of the more than 2.5 million eligible low-income children. The structure of conventional care providers may be insufficient to meet the more complex and interrelated needs of the at-risk family. Experts believe that at-risk families need an array of services or, at minimum, close coordination among complementary service providers. A pregnant teen, for example, may need, in addition to regularly scheduled medical visits, an array of more comprehensive services, including counseling and basic parenting instruction. Generally, a mix of related services in one location or near one another, or adequate linkages among these services, does not exist for at-risk families. Personal beliefs, knowledge, and attitudes can present additional barriers to getting care. Some researchers have found that some low-income families do not understand or value the need for preventive services. They may distrust health care providers or 2Medicaid is a federally aided, state-administered medical assistance program for needy people, authorized under title XIX of the Social Security Act. 3Institute of Medicine, Prenatal Care: Reaching Mothers, Reaching Infants, ed. by Sarah S. Brown (Washington, D.C.: National Academy Press, 1988), pp. 63-69. 12 social workers. These personal barriers are particularly evident in families experiencing social or cultural isolation resulting from recent immigration, a lack of friends and relatives that can provide emotional support, or substance abuse. Experts view home visiting as one way to bridge some of these gaps. Providing services to families directly in the home allows programs to reach out directly to families who may be facing these barriers. The Office of Technology Assessment, the National Academy of Sciences' Institute of Medicine, the National Commission to Prevent Infant Mortality, and various private organizations and foundations (such as the Pew Charitable Trusts) suggest that home visiting allows programs to -- reach parents who lack self-confidence and trust in formal service providers, -- obtain a more accurate and direct assessment of the home environment, -- link parents with other health and human services, and -- present a model for good parenting. Home visitors can support families during major life changes, such as the birth of a baby. Such personalized support may be particularly useful for disadvantaged families and families headed by teens who suffer from isolation and a lack of an intact social support system. HOME VISITING AS AN EARLY INTERVENTION STRATEGY ----------------------------------------------- Home visiting is often used as one means to provide early intervention services. Early intervention seeks to improve families' lives and prevent problems before they become irreversible or extremely costly. For example, -- prenatal care seeks to promote the health and well-being of the expectant mother and developing fetus, thereby reducing poor birth outcomes, such as low birthweight; -- parenting skills instruction for adolescent mothers with infant children seeks to promote nurturing skills, thereby reducing abusive and neglectful behavior; and -- preschool education seeks to prepare children for learning, thereby reducing later school failure. The costs associated with low birthweight, teen motherhood, child abuse and neglect, and school dropouts are high. The cost to the nation of low birthweight babies in neonatal intensive care is 13 $1.5 billion annually.#4 The combined Aid to Families With Dependent Children, Medicaid, and Food Stamps cost in 1988 for families in which the first birth occurred when the mother was a teen was estimated at $19.83 billion.#5 The immediate, first- year public costs of new reported child abuse cases in 1983 were estimated at $487 million for medical care, special education, and foster care,#6 and since then the number of child maltreatment cases reported has gone up by 47 percent. Recent estimates suggest that each year's high school dropout "class" will cost the nation more than $240 billion in lost earnings and forgone taxes.#7 Early intervention can save money. For example, for most American families, a child's measles inoculation is considered a standard part of well-child care. But forgoing such immunizations--which is happening more frequently--has costly consequences. Lifetime institutional care for a child left retarded by measles is between $500,000 and $1 million. Researchers have reported the potential of this and other early intervention strategies to save money, as shown in table 1.1. Experts believe that home visiting can be a key mechanism for reaching families early with the preventive services they need. Table 1.1: Early Intervention Saves Money Every $1 spent on: Saves.... ------------------ --------- The federal Childhood $10 in later Immunization Program medical costs.(1) Prenatal care $3.38 in later medical costs for low birthweight infants.(2) Preschool Education $3-6 in later remedial education, welfare, and crime control.(3) 4"Special Report: Perinatal Issues 1989," American Hospital Association, Chicago (1989), p. 2. 5"Teenage Pregnancy and Too-Early Childbearing: Public Costs, Personal Consequences," Center for Population Options, Washington, D.C. (1989), p. 3. 6Deborah Daro, Confronting Child Abuse: Research for Effective Program Design, The Free Press, New York (1988), pp. 155-57. 7Children in Need: Investment Strategies for the Educationally Disadvantaged, The Committee for Economic Development, New York (1987), p. 3. 14 Sources: 1. University of North Carolina Child Health Outcomes Project, Monitoring the Health of America's Children, Sept. 1984. 2. Institute of Medicine, Preventing Low Birthweight (Washington, D.C.: National Academy Press, 1985). 3. John R. Berrueta-Clement and others, Changed Lives: The Effects of the Perry Preschool Program on Youths Through Age 19, Monographs of the High/Scope Educational Research Foundation, Number 8, The High/Scope Press, 1984. OBJECTIVES, SCOPE, AND METHODOLOGY ---------------------------------- Our objectives in reporting on home visiting were to determine -- the scope and nature of existing home-visiting programs in the United States and Europe that focus on maternal and child health and well-being; -- the effectiveness of home visiting as a service delivery strategy; -- the factors and strategies critical to designing home visitor programs; and -- program and policy options for the Congress and the Departments of Health and Human Services and Education in using home visiting as a strategy to improve maternal and child health and well-being. To accomplish our first two objectives, we reviewed the literature on home visiting and interviewed experts in the areas of medical, social, and education intervention. In reviewing the literature, we especially looked for research-based evaluations of home visiting that reported program results and costs. We used this information, along with site visits to programs in the United States and Europe that used home visiting as a service delivery strategy, to accomplish our third objective--developing a framework of key design characteristics. We identified and discussed seven key design characteristics with various home-visiting experts who concurred that these characteristics were important for developing and operating effective programs. Through our case studies, we observed these design characteristics in operation and subsequently combined these seven elements into four to form the basis for our framework. Programs we selected for study were cited, either in the literature or by experts, as being successful in meeting their 15 objectives. We did not conduct our own evaluation of the effectiveness or impact of these programs or conduct a comparative analysis of effectiveness of different service delivery strategies, such as home-based versus center-based services. While we identified many service areas that used home visiting, including home health care for the chronically ill or the elderly, we focused on programs serving families from the prenatal period through a child's second birthday. From a list of 31 programs suggested by experts or the literature as being successful in meeting their objectives using home visiting, we conducted standardized telephone interviews to collect information about program objectives and structure. We judgmentally selected six U.S. programs to provide diversity among program characteristics. Primary selection factors included programs -- with different objectives, -- operating in urban and rural areas, -- with different target populations, and -- using home visitors with different backgrounds (for example, nurses, paraprofessionals, lay workers). In addition, we selected Great Britain and Denmark because of their long-standing tradition and experience in using home visitors to deliver maternal and child health services. At each site we interviewed senior program managers, home visitors, and their supervisors. We interviewed representatives of other local service providers at five of six U.S. locations. In addition, in Great Britain and Denmark, we interviewed officials from the National Health Service, local health authorities, Great Britain's Health Visitors Association, and a Danish member of Parliament. We also accompanied home visitors on their rounds in the United States, Great Britain, and Denmark. At the federal level, we contacted officials in the Departments of Health and Human Services and Education responsible for programs using home visiting to improve the health and well-being of mothers and young children. We reviewed agency documents to identify programs that have funded home visiting. We did our work between December 1988 and February 1990 in accordance with generally accepted government auditing standards. We did not, however, verify program cost information. 16 CHAPTER 2 --------- HOME VISITING IS AN ESTABLISHED ------------------------------- SERVICE DELIVERY STRATEGY ------------------------- WITH MULTIPLE OBJECTIVES ------------------------ Home visitors have provided early intervention services in the United States and Europe for more than 100 years. In Great Britain and Denmark, home visiting is provided without charge to almost all families with young children. In the United States, home visiting is not universally available. It is conducted on a project-by-project basis, by governmental and private organizations, primarily targeted to "special needs" families. Governmental support for home-visiting is split among many agencies and programs. The federal government's involvement and interest in home visiting is apparent from its many programmatic activities, recently enacted laws, and proposed legislation. Many states are using project grants and formula funding from recent legislation, such as Medicaid, to expand home visiting in their states. The Congress authorized new home-visiting demonstration grants in the 101st Congress, although it did not appropriate funds. Despite such initiatives, we found only limited information exchange about home visiting experiences across program lines. HOME VISITING WIDESPREAD IN EUROPE ---------------------------------- Home visiting is a common part of Western European maternity care.#8 Home visitors may be midwives, but most often are specially trained nurses. Usually women are visited at home after a child's birth (postpartum). Nine European countries provide prenatal and/or postpartum home visiting either routinely or for special indications, such as clinic nonattendance. (See table 2.1.) Seven countries routinely provide at least one postpartum home visit. 8C. Arden Miller, M.D., Maternal Health and Infant Survival, National Center for Clinical Infant Programs, Washington, D.C. (1987). 17 Table 2.1: Home Visiting in Nine Western European Countries Country Prenatal Postpartum ------- -------- ---------- Belgium Xa X Denmark Xa Xb Germany O O Great Britain O X France O O Ireland O X Netherlands X X Norway O X Switzerland O X Legend: X Home visiting is provided at least once for all pregnant women or new mothers. O Home visiting is provided under special circumstances, such as follow-up for a woman not attending prenatal clinic. aUnevenly implemented. bIn municipalities that have home visitors (94 percent of all Danish municipalities). Source: C. Arden Miller, M.D., Maternal Health and Infant Survival. In the two European countries that we visited, Great Britain and Denmark, home visiting is a main source of preventive health information and care for young children. It began, however, as a way to reduce infant mortality. Home visiting was begun in Great Britain in 1852 by a local voluntary group in Manchester and Salford. In 1890, Manchester became the first locality to employ a home visitor. By 1905, 50 areas employed home visitors. When Great Britain created the National Health Service in 1948, home visitors were included as a profession. Today home visitors serve all British families with young children. Home visiting in Denmark started as a pilot program in 1932 and was established by law in 1937. Although the service has always been optional, nearly every township has a nurse home-visiting program today. Ninety percent of all Danish infants live in counties served by home visitors. Home visiting in Great Britain and Denmark is provided free of charge as a publicly supported