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. __________________________________________________________________ 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 service to families with young children regardless of family income. It is an established part of preventive health services in national health care systems to 18 which all citizens have access. Home visitors teach parents good health practices and provide preventive health services and medical screenings to infants and children directly in their homes. In Great Britain, home visitors meet mothers-to-be at the clinic, and then follow the child after birth--through both in- home and clinic visits--until the child reaches school age. In Denmark, home visitors begin visiting the family soon after a child is born and visit each child several times during the first year. Universal home visiting has certain benefits. Such an approach can attract wider political acceptance with no stigma attached to receiving the services. In the opinion of public health officials in Denmark and Great Britain, home visiting promotes good health practices and has become an important part of preventive health care in their countries. However, neither country has a system to evaluate home-visiting program benefits. Both Great Britain's and Denmark's home-visiting programs are facing change. Great Britain is reexamining its health service, with an eye to making it more effective and economical. As a result, British local health authorities are beginning to develop local measures of home-visiting effectiveness. Because of a shortage of home visitors, local health authorities are beginning to target their services more closely to local needs and to at- risk families. Health officials believe that in the future, home visitors will visit each family in home at least once, but reserve follow-up and more intensive in-home service to families they deem at risk. Low-risk families will be followed in the clinic. Denmark is reviewing its health service and may require each county to make home-visiting services available. However, Denmark may also begin charging fees for home-visiting services. U.S. HOME VISITING TARGETED TO LOW-INCOME AND SPECIAL NEEDS ----------------------------------------------------------- FAMILIES -------- Home visiting in the United States had a similar beginning to that in Great Britain and Denmark, but its development has been much less systematic and uniform. Nevertheless, many local public and private agencies provide home visiting. Compared to Europe, U.S. programs that provide home visiting are diverse in their goals and are likely to be targeted to families with special needs, such as families with handicapped children or children not developing normally. Home visiting began in the United States during the 19th century to improve the health and welfare of the poor. In 1858, well-to- do volunteers became "Friendly Visitors" to poor families in Philadelphia, and the movement later spread to other large 19 Eastern cities. In the early 20th century, settlement houses#9 began to send visiting nurses, teachers, and social workers into poor families' homes to provide education, preventive health care, and acute care. This effort was initially fueled by a growing awareness that prenatal care and proper infant care could improve the survival of infants. Visiting nurse programs evolved from these beginnings. During the 1970s, home visiting to improve low-income children's school readiness was encouraged through Head Start#10 demonstration projects. Today Head Start, although primarily a center-based program, administers one of the largest home-visiting programs for low-income families in the United States, serving over 35,000 children yearly. Targeted Programs With Diverse Goals ------------------------------------ Many programs in the United States use home visiting to provide health, social, or educational services to certain families. Programs using home visiting are generally targeted to families with special needs, such as those with developmentally delayed children or abused children. These programs provide specialized services depending on the program focus and families' needs. Very limited data are available to quantify the number of programs using home visiting. However, two researchers, Richard Roberts and Barbara Wasik, have recently attempted to develop the first comprehensive picture of such programs.#11 In 1988, they surveyed over 4,500 programs in the United States that appeared to use home visiting as a service delivery technique. Of the 1,900 programs for which they obtained detailed data, 76 percent were targeted toward families with particular problems, such as abusive parents or parents with physically handicapped children. One-third of the programs served children in the 0-3-year-old range. Unlike in Europe, where preventive health care is the main purpose, Roberts and Wasik found that in the United States, many home-visiting programs focus on education or social services. Only a third of the programs responding listed health as the 9Community centers established in poor urban neighborhoods where trained workers tried to improve social conditions by providing such services as kindergartens and athletic clubs. 10A national program providing comprehensive developmental services, including educational, health, and social services, primarily to low-income preschool children age 3 to 5 and their families. 11Barbara Hanna Wasik and Richard N. Roberts, "Home Visiting Programs for Low-Income Families," Family Resource Coalition Report, No. 1 (1989). 20 primary focus. Overall, 43 percent of the responding programs were either education or Head Start programs. Only 22 percent of the programs targeted to low-income families served expectant families before birth and children up to age 3, compared with 43 percent of programs not specifically targeted to low-income families. Head Start programs represented 45 percent of programs targeted specifically to low-income families. However, Head Start primarily serves children age 3 to 5 years. FUNDING FOR U.S. HOME VISITING FROM MULTIPLE AGENCIES ----------------------------------------------------- Federal and state governments support home visiting through many programs, with both one-time project funds and ongoing funding sources. We could not determine the full extent of federal funding for home visiting, because federal managers we interviewed did not know the extent to which states were using federal monies to fund home visiting. Federal managers were not always aware of results of effective programs funded by other agencies, the materials developed, or of state efforts in home visiting. The Departments of Health and Human Services and Education have provided funds for home visiting to families with young children through various programs and through both project and formula grants. (See table 2.2.) Project grants are given directly to public or private agencies to finance specific projects, such as developing model programs. Formula grants are given to states, their subdivisions, or other recipients according to a formula (usually related to population) for continuing activities not confined to a specific project. States often have to match federal formula grant funds with state-contributed funds. 21 Table 2.2: Federal Programs Used to Fund Home Visitor Projects#a Agency Office Program Type ------ ------ ------- ---- Department of Health and Human Services --------------------------------------- Office of Head Start Home-Based Project Human Head Start grant Development Services/ Head Start Parent Child Project Administration Centers grant for Children, Youth, and Head Start Comprehensive Project Families Child grant Development Centers National Center Child Abuse and Formula on Child Abuse Neglect grant and Neglect "Challenge" Grants National Center Child Abuse and Project on Child Abuse Neglect Research grant and Neglect and Demonstration Grants Public Maternal Maternal and Formula Health and Child Child Health grant Service Health and Services Block Resources Grant Development Maternal Special Projects Project and Child of Regional and grant Health and National Resources Significance Development (SPRANS)#b Health Bureau of Medicaid Formula Care Program grant#c Financing Operations Administration Department of Education ----------------------- Office of Education of the Formula Special Handicapped Act grant Education Part B & H Programs Programs 22 Chapter 1 Formula Handicapped grant Program#d Handicapped Project Children's Early grant Education Program aHome visiting may be funded by other federal programs not identified by GAO and not listed here. bThese projects are funded by a federal set-aside of 10 to 15 percent of the Maternal and Child Health Block Grant appropriation. cMedicaid is a joint federal-state program that entitles eligible persons to covered medical services. The federal government matches state payments to providers and administrative costs using a formula based on state per capita income. dThe Chapter 1 Handicapped Programs of the Education Consolidation and Improvement Act of 1981 provide grants to states to expand or improve educational services to handicapped children. States have supported home visiting through their use of both federally funded formula grants and state funds. For example: -- Tennessee, Michigan, and Delaware have used federal child abuse and neglect "challenge" grant funds to support home- visiting programs. -- Hawaii has used both state funds and Maternal and Child Health Services (MCH) block grant#12 funds to expand to more sites a home-visiting program to prevent child abuse and neglect. -- Missouri has funded a universal, educational home-visiting program, "Parents as Teachers," using state education funds. -- Maine is trying to establish public health nurse home visiting for every newborn, using state public health funds and MCH block grant funds. The Departments of Health and Human Services (HHS) and Education did not know the full amount of federal funds spent for early intervention services for children who are handicapped, 12The MCH block grant is a federal formula grant awarded annually to state health agencies to assure access to quality maternal and child health services, reduce infant mortality and morbidity, and provide assistance to children needing special health services. 23 developmentally delayed, or at risk of developmental delay. Also, most federal managers we contacted could not tell us the amount of funding their programs were providing for home visiting as an early intervention service delivery for at-risk children. Managers at the federal level could provide examples of federally funded demonstration programs that used home visiting, but were not sure of the extent to which states were using formula grants to fund home visiting. Clearly, many sources of federal support for home visiting are available. But overall funding information is limited. With the exception of Home-Based Head Start, home visiting has never been the primary focus of any federal programs. Despite this federal and state commitment to home visiting, we found only limited information exchange about home visiting across program lines. For example, Head Start has developed materials for home visitors, including The Head Start Home Visitor Handbook and A Guide for Operating a Home-Based Child Development Program. However, some program officials in other HHS agencies were not aware that these guides existed and thus could not share them with projects they were supervising. Some federal officials did not know that states were providing home visiting using federal formula funds. Health Care Financing Administration officials we contacted who manage the Medicaid program were not aware that some states were providing preventive prenatal services in the home as part of the state Medicaid program. Some of the clearinghouses funded by federal agencies that have supported home visiting cannot readily provide information on that topic. The Education Resources Information Center, a clearinghouse that the Department of Education supports, was able to identify resource materials on home visiting. However, two HHS-funded clearinghouses, the National Maternal and Child Health Clearinghouse and the Clearinghouse on Child Abuse and Neglect Information, could not readily identify resource materials on home visiting to improve maternal and child health outcomes or to prevent abuse and neglect. NEW IMPETUS FOR HOME VISITING FROM RECENT LEGISLATION ----------------------------------------------------- Several recently enacted laws include provisions that may encourage home visiting. The Education of the Handicapped Act Amendments of 1986, recent Medicaid prenatal care expansions, and the 1988 Child Abuse Prevention, Adoption, and Family Services Act provide options for states to fund home visiting. Recently introduced bills also contain provisions to encourage home visiting through earmarked program funds and through additional Medicaid changes. 24 Public Law 99-457 May Broaden Availability of Home Visiting ----------------------------------------------------------- The Education of the Handicapped Act Amendments of 1986, Public Law 99-457, may further encourage home visiting. Through the addition of Part H, the statute authorized financial assistance to assist states in developing and implementing statewide, comprehensive early intervention services for developmentally delayed and at-risk infants and toddlers and their families. The legislation extended program benefits to children aged birth through 2 years in states choosing to participate. The Department of Education has indicated that home visiting, while optional, is among the minimum services that should be provided to eligible children. States must serve a core group of developmentally delayed children, but at their discretion can also serve children who are at risk of developmental delay. Developmental delay includes delays in one or more of the following areas: cognitive development, physical development, language and speech development, psychosocial development, and self-help skills. Children with a diagnosed physical or mental condition that has a high probability of resulting in developmental delay are also eligible. Children can be classed as "at risk" due to either environmental or biological risk factors. Environmental risk factors for children could include poverty, having a teen parent, or being homeless. The legislation gives states flexibility in defining developmental delay and setting eligibility and service delivery standards. However, once the standard is set, all children in the state who are eligible are entitled to services. State programs must be in place and serving all eligible children by a state's fifth year of participation, which could be as early as July 1991 for states that have participated in the program continuously since its inception in fiscal year 1987. To help mobilize resources and facilitate state implementation of Public Law 99-457, agencies within the Department of Education and HHS created the Federal Interagency Coordinating Council (FICC). FICC's mission is to develop specific action steps that promote a coordinated, interagency approach to sharing information and resources in five areas: (1) regulations, program guidance, and priorities; (2) parent participation; (3) identification of children needing services; (4) materials and resources; and (5) training and technical assistance. (See table 2.3 for participating agencies.) FICC-supported activities include an annual Partnerships for Progress conference, which has been used to disseminate information to state officials on innovative programs as well as on funding sources that can be used to pay for services. Another joint project was the development and distribution of a reference book for schools attended by children who are dependent on medical technology, such as children who need regular renal dialysis. The Bureau of Maternal and Child Health and Resources Development and 25 representatives of FICC also sponsored a February 1988 conference and subsequent publication, Family Support in the Home: Home Visiting Programs and P.L. 99-457, to provide guidelines and recommendations for using home visiting as a service delivery mechanism under the statute. Table 2.3: Signatories to the FICC Memorandum of Understanding Signatories ----------------------------------------------- Department Principal Other ---------- --------- ----- Education Assistant Secretary, Director, Office of Special Office of Special Education and Education Programs Rehabilitative Services Director, National Institute on Disability and Rehabilitation Research HHS Assistant Secretary, Commissioner, Office of Human Administration for Development Services Children, Youth and Families Commissioner, Administration on Developmental Disabilities Assistant Secretary Director, for Health National Institute on Mental Health Administrator, Health Resources and Services Administration Director, Bureau of Maternal and Child Health and Resources Development Director, Office of the Associate Director for Maternal and Child Health 26 Administrator, Health Care Financing Administration States Are Using Medicaid to Fund Home Visiting ----------------------------------------------- Medicaid has become a more significant source of funding for pre- and postnatal services as Medicaid eligibility has expanded to cover more low-income women. Beginning with the Deficit Reduction Act of 1984, the Congress expanded Medicaid coverage of pregnant women and children, primarily by severing the link between eligibility for Medicaid and Aid to Families With Dependent Children (AFDC).#13 As of April 1, 1990, states are required to cover pregnant women and children up to age 6 with family income up to 133 percent of the federal poverty level. At their option, states can also cover children up to age 8 with income up to 133 percent of federal poverty and pregnant women and infants up to age 1 with family income from 133 percent to 185 percent of the federal poverty level. In states that allow Medicaid payment for home visiting, Medicaid can serve as an ongoing funding source. The Consolidated Omnibus Budget Reconciliation Act of 1985 permits states to obtain federal matching funds when offering more extensive or "enhanced" prenatal care services to low-income pregnant women. These kinds of services do not have to be made available to other Medicaid recipients. States may add case management and extra prenatal care services by amending their state plans. While home visiting is not specifically listed as a covered Medicaid service, some states have used their authority under the 1985 act to obtain reimbursement for in-home case management services or other in- home services to certain pregnant women. New Jersey, for example, requires at least one prenatal and postpartum home visit for high-risk women being served through its Medicaid-funded enhanced prenatal care program. According to the National Governors' Association and the National Commission to Prevent 13Medicaid eligibility for pregnant women and children had been linked to actual or potential receipt of cash assistance under the AFDC program or the Supplemental Security Income program. To be eligible for these programs, income and assets cannot be above specified levels. On average across the states, a family's annual income in 1989 had to fall below 48 percent of the federal poverty level to qualify for AFDC, with income limits ranging from 14.0 percent ($1,416 for a family of three) in Alabama to 79.0 percent ($7,956) in California. The 1989 federal poverty level for a family of three was $10,060. 27 Infant Mortality, as of February 1990, 24 states#14 were using Medicaid to pay pre- and/or postnatal care providers for home visiting. Home Visiting Is Encouraged to Prevent Child Abuse and Neglect -------------------------------------------------------------- The Child Abuse Prevention, Adoption, and Family Services Act of 1988 recognized home visiting as an appropriate strategy for preventing child abuse and neglect. This act focused federal efforts to aid states and localities in preventing child abuse as well as intervening once abuse had occurred. The legislation reauthorized a state formula grant program that "challenges" states to establish earmarked funding for child abuse and neglect prevention programs by providing a 25-percent federal dollar match. States have used challenge grant monies to support home- visiting services. Increased Interest in Home Visiting in Recent Legislative --------------------------------------------------------- Proposals --------- Several legislative proposals that addressed home visiting were introduced in the 101st Congress: -- The Healthy Birth Act of 1989 (H.R. 1710 and S. 708) proposed an increased authorization of $100 million to the MCH block grant program to fund various additional projects, including home visiting. -- The Maternal and Child Health Improvement Act of 1989 (H.R. 1584) proposed an increased authorization of $50 million for the MCH block grant program, to be used partially for home visiting. -- The Maternal and Child Health Block Grant Amendments of 1989 (H.R. 2651) proposed an increased authorization of $100 million for the MCH block grant program, with a set-aside to fund home visiting demonstrations. -- The Child Investment and Security Act of 1989 (H.R. 1573) proposed to require Medicaid coverage of prenatal and postpartum home-visiting services. -- The Omnibus Budget Reconciliation Act of 1989 (H.R. 2924), The Infant Mortality Amendments of 1990 (S. 2198), and The Medicaid Infant Mortality Amendments of 1990 (H.R. 3931) proposed that prenatal home-visiting services for high-risk 14Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, Idaho, Kansas, Maryland, Michigan, Minnesota, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Tennessee, Utah, Vermont, Virginia, and Washington. 28 pregnant women and postpartum home-visiting services for high- risk infants up to age 1 be made optional Medicaid services. The Congressional Budget Office estimated that if home visiting was made an optional Medicaid service, as proposed in H.R. 2924, the additional federal Medicaid cost would be $95 million over a 5-year period for fiscal years 1990-94. If the services were mandatory, as was proposed in H.R. 1573, the estimated additional 5-year federal cost could go up to $625 million. None of this legislation was passed as introduced, as of June 1990. However, the Congress did authorize, through the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239), new home- visiting demonstration projects to be funded through a set-aside from the MCH block grant when its funding level exceeds $600 million (currently at $561 million). 29 CHAPTER 3 --------- HOME-VISITING EVALUATIONS DEMONSTRATE BENEFITS, ----------------------------------------------- BUT SOME QUESTIONS REMAIN ------------------------- Evaluations of early intervention programs using home visiting have shown that children and their families had improved health and well-being, compared to families who did not receive services. This was particularly true for families who are among groups that often face barriers to needed care, such as adolescent mothers, low-income families, and families living in rural areas. In a few cases where follow-up studies were done on programs that combined home and center-based services, these salutary effects persisted over time as children developed. More intensive services seemed to produce the strongest effects. But few experimental research initiatives have compared home visiting to other strategies for delivering early intervention services. Cost data, while limited, indicate that providing home-visiting services for at-risk families can be less costly than paying for the consequences of the poor outcomes associated with delayed or no care. Evaluations have also not adequately addressed whether home visiting is more costly than providing similar services in other settings. PROGRAM EVALUATIONS SHOW BENEFITS OF HOME VISITING -------------------------------------------------- Evaluations of early intervention programs that used home visiting show that this strategy can be associated with a variety of improved outcomes for program participants--improved birth outcomes, better child health, improved child welfare, and improved development--when compared to similar individuals who did not receive services. In addition to being at risk for adverse outcomes, the target population for these programs often belonged to groups that experience difficulty accessing needed services. Examples of improved outcomes associated with home visiting include the following: -- Pregnant adolescents in rural areas visited by the South Carolina Resource Mothers Program had half the percentage of small-for-gestational-age infants and significantly fewer low birthweight babies compared to a similar group of pregnant adolescents in a rural county without such a program.#15 15Henry C. Heins, Jr., and others, "Social Support in Improving Perinatal Outcome: The Resource Mothers Program," Obstetrics and Gynecology, Vol. 70, No. 2 (Aug. 1987). 30 -- Low-income mothers visited in Michigan gave birth to babies with significantly improved birthweight and health at birth, compared to both their previous pregnancies and to a control group with similar demographic characteristics.#16 -- Children in working class families randomly assigned to a group that received home-visiting services had significantly fewer accidents in their first year and had a better rate of immunizations than children who were not visited. The home visiting was more successful when it began prenatally.#17 -- For several home-visiting projects, participants had a lower reported incidence of child abuse and neglect than that found in similar families.#18 Children at risk of developmental delay have also benefited from services delivered through home visiting. Premature low birthweight babies and malnourished children whose families were seen by home visitors were able to physically and developmentally "catch up" to their healthier peers.#19 For example: -- Fewer low birthweight children in a Florida program needed additional developmental services after graduating from a 16Jeffrey P. Mayer, "Evaluation of Maternal and Child Health Community Nursing Services: Application of Two Quasi-Experimental Designs," Health Action Papers, Vol. 2 (1988). 17Charles P. Larson, "Efficacy of Prenatal and Postpartum Home Visits on Child Health and Development," Pediatrics, Vol. 66, No. 2 (Aug. 1980). 18U.S. Congress, Office of Technology Assessment, Healthy Children: Investing in the Future, OTA-H-345 (Washington, D.C.: U.S. Government Printing Office, Feb. 1988); Deborah Daro, Confronting Child Abuse: Research for Effective Program Design, The Free Press, New York, 1988. 19Tiffany M. Field and others, "Teenage, Lower-Class, Black Mothers and Their Preterm Infants: An Intervention and Developmental Follow-up," Child Development, Vol. 51 (1980); Virginia Rauh and others, "Minimizing Adverse Effects of Low Birthweight: Four-Year Results of an Early Intervention Program," Child Development, Vol. 59, (1988); Gail S. Ross, "Home Intervention for Premature Infants of Low-Income Families, "American Journal of Orthopsychiatry, Vol. 54, No. 2 (Apr. 1984). 31 randomly assigned 2-year home-visiting program compared to children who received no services.#20 -- Three years after the program ended, children in Jamaica who were home visited to help them overcome the effects of malnutrition had significantly higher IQ scores than malnourished children with similar medical and demographic characteristics who had not received services.#21 Other programs have also found significant improvements in the cognitive ability of rural and inner-city children who had been provided with preschool services through home visiting, compared to children who were not provided with such services.#22 Benefits to Families Can Persist Over Time ------------------------------------------ The full effects of early intervention programs using home visiting as part of their service delivery can become more impressive as parents use what they have been taught and children grow and further develop. Such contact during a child's early years often results in improved family functioning, better school performance, and better outcomes after high school. We identified several programs with longitudinal evaluations that had provided both center- and home-based services. From 1962 to 1967, the High/Scope Perry Preschool Program, in Ypsilanti, Michigan, provided both weekly home visits for the parents of low-income, 3- and 4-year-olds and comprehensive center-based preschool services for the children. Children from the families who agreed to participate were randomly assigned to either a group that received preschool and home visiting or a control group. Participants scored significantly higher on tests of intellectual ability after 1 year in the program and did better on standardized testing through the middle grades, than 20Michael B. Resnick and others, "Developmental Intervention for Low Birth Weight Infants: Improved Early Developmental Outcomes," Pediatrics, Vol. 80, No. 1 (July 1987). 21Sally Grantham-McGregor and others, "Development of Severely Malnourished Children Who Received Psychosocial Stimulation: Six Year Follow-up," Pediatrics, Vol. 79, No. 2 (Feb. 1987). 22Donna M. Bryant and Craig T. Ramey, "An Analysis of the Effectiveness of Early Intervention Programs for Environmentally At-Risk Children," in The Effectiveness of Early Intervention for At-Risk and Handicapped Children, ed. Michael J. Guralnick and Forrest C. Bennett, Academic Press, Inc. Orlando (1987); Charles W. Burkett, "Effects of Frequency of Home Visits on Achievement of Preschool Students in a Home-Based Early Childhood Education Program," Journal of Educational Research, Vol 76, No. 1 (Oct. 1982). 32 did the control children. At age 15, they placed a higher value on schooling. For many of these children, early school success served as a preparation for greater life success. At age 19, young people who had participated in the program were more likely to be literate and employed or in college. They were less likely to have dropped out of school, to be on welfare, or to have been arrested.#23 (See fig. 3.1.) One reviewer looking at the effects of preschool pointed to the High/Scope Perry Preschool's home visiting as being a significant factor in its success.#24 23Lawrence J. Schweinhart and David B. Weikart, "The High/Scope Perry Preschool Program," in 14 Ounces of Prevention: A Casebook for Practitioners, Richard H. Price and others, ed., American Psychological Association, Washington, D.C. (1988). 24Ron Haskins, "Beyond Metaphor: The Efficacy of Early Childhood Education," American Psychologist, Vol 44, No. 2 (Feb. 1989). 33 Figure 3.1: Students Receiving Preschool and Home-Visiting Services Were More Successful in Later Years (Could not be reproduced for electronic viewing.) Note: Results show comparative outcomes at age 19 for High/Scope Perry Preschool children compared to the randomly selected control group. The Yale Child Welfare Research Program also had impressive results over time. A group of 17 families received home visiting along with developmental day care and close pediatric supervision. The control group, chosen the following year, was another group of families with similar characteristics who did not receive program services. Ten years later, more home-visited families than control group families were employed and had moved to improved housing. Their children were doing better in school. Teachers rated the program-participating children as better 34 adapted socially and needing fewer remedial school services than the control children.#25 Intense Programs Have More Marked Effects ----------------------------------------- Evaluations of early intervention programs using home visiting and varying in service intensity--the amount of program contact with clients over time--found that more intense programs are generally more effective. An evaluation of a program in Jamaica that provided home-visiting services to improve low-income children's cognitive development found that children who were visited weekly showed the most marked improvement in development, compared to children who were randomly assigned to receive less frequent or no services. Children visited every 2 weeks also showed significant improvement in cognitive development, but not as great as those visited weekly. The children visited monthly showed a similar developmental pattern to the children receiving no services.#26 Intensive home visiting, in conjunction with medical and educational interventions, has proven effective at keeping IQ scores of groups of randomly assigned disadvantaged children from dropping over time, compared to those of control groups. A comparative evaluation of 17 programs, 11 of which used home visiting, showed that program effectiveness increased as other services were combined with home visiting. Two of the three most effective and most intensive programs used home visiting in addition to center-based services.#27 The Brookline, Massachusetts, Early Education Project is an example of home visiting as a crucial service component for reaching disadvantaged families. This experimental program randomly assigned recruited families to varying levels of drop- in, child care, and home-visiting services provided from infancy through the preschool years. Children of mothers who had not graduated from college and who received only center-based 25Victoria Seitz and others, "Effects of Family Support Intervention: A Ten-Year Follow-up," Child Development, Vol. 56 (1985). 26Christine Powell and Sally Grantham-McGregor, "Home Visiting of Varying Frequency and Child Development," Pediatrics, Vol. 84, No. 1 (July 1989). 27Donna M. Bryant and Craig T. Ramey, "An Analysis of the Effectiveness of Early Intervention Programs for Environmentally At-Risk Children," in The Effectiveness of Early Intervention For At-Risk and Handicapped Children, Michael J. Guralnick and Forrest C. Bennett, ed., Academic Press, Inc. (1987). 35 services were almost twice as likely to have reading difficulties in second grade as similar children who had received both home- and center-based services.#28 (See fig. 3.2.) Figure 3.2: Type and Amount of Services Affect Later Reading Ability (Could not be reproduced for electronic viewing.) Source: "The Brookline Early Education Project," Donald E. Pierson in 14 Ounces of Prevention: A Casebook for Practitioners, Richard H. Price and others, American Psychological Association, Washington, D.C. (1988). 28Donald E. Pierson, "The Brookline Early Education Project," in 14 Ounces of Prevention: A Casebook for Practitioners, Richard H. Price and others, ed., American Psychological Association, Washington, D.C. (1988). 36 RESEARCH SHOWS HOME VISITING COMPARED TO OTHER STRATEGIES IS ------------------------------------------------------------ PROMISING, BUT MORE STUDY IS NEEDED ----------------------------------- Whether one early intervention strategy is more effective than another is difficult to determine from the literature because few programs were developed and operated as part of a controlled experiment or quasi-experiment. Many programs demonstrating benefits to clients delivered both in-home and center-based services, but did not try to determine which had the greater impact or which was the most cost-effective. We identified two comparative studies that examined the differential effects of early intervention service delivery strategies. Beginning in 1978, Elmira, New York, was the site of a major and often-cited research experiment using home visitors as a service delivery strategy. First-time mothers, particularly teenage, single, or poor mothers, were recruited for the program and then randomly assigned to one of four treatments: (1) no program services during pregnancy, (2) free transportation to prenatal care and well-baby visits, (3) nurse home visiting during pregnancy and transportation services, or (4) nurse home visiting during pregnancy and until the child's second birthday, in addition to transportation services. The program had both short- and long-term positive effects for the home-visited mothers and their children when compared to those receiving only transportation to health clinics or no services. The positive effects of those visited in the home, compared to the women who were not visited, included the following: -- Higher birthweight babies born to teen mothers and smokers. -- Fewer kidney infections during pregnancy. -- Fewer verified cases of child abuse and neglect. -- Four years later, more months of employment, fewer subsequent pregnancies, and postponed birth of second child.#29 A primary reason for using home visitors is to reach families who might otherwise not have access to services, such as rural families living in isolated areas, or families who might avoid 29David L. Olds and others, "Improving the Delivery of Prenatal Care and Outcomes of Pregnancy: A Randomized Trial of Nurse Home Visitation," Pediatrics, Vol. 77, No. 1 (Jan. 1986); David L. Olds and others, "Preventing Child Abuse and Neglect: A Randomized Trial of Nurse Home Visitation," Pediatrics, Vol. 78, No. 1 (July 1986); David L. Olds and others, "Improving the Life-Course Development of Socially Disadvantaged Mothers: A Randomized Trial of Nurse Home Visitation," American Journal of Public Health, Vol. 78, No. 11 (Nov. 1988). 37 formal service providers, such as abusive families. Home-Based Head Start is an example of a program that provides services through home visiting predominantly to rural children who could not take advantage of the traditional center-based Head Start program. Although the children were not randomly assigned to the two different service delivery strategies, an evaluation of the Home-Based Head Start program found that, after statistically adjusting for initial group differences, children from home- based, center-based, and mixed home- and center-based Head Start programs tested equally well in cognitive ability and social development following their participation in preschool activities.#30 LIMITED RESEARCH SHOWS HOME VISITING CAN PRODUCE COST SAVINGS ------------------------------------------------------------- Evaluations that analyze home visiting's costs and benefits, while few in number, have shown that programs incorporating home visiting as a service delivery strategy can prevent families from needing later, more costly public supportive services. Cost savings become more obvious when examined by longitudinal studies or when initial costs for alternate solutions are high. Whether home-based services are more expensive than providing similar center-based services depends on a program's objectives, services, and type of provider. Few true cost-effectiveness studies have been done. Of the 72 published evaluations we reviewed that identified the effects of home visiting, only 8 discussed program costs and only 6 had estimates of immediate or future cost savings. Yet the results of these studies are compelling. They represent findings from studies with rigorous experimental or quasi- experimental designs, and several are often cited in the early intervention literature. The High/Scope Perry Preschool Program evaluators estimated that the program--with its critical home-visiting component--saved from $3 to $6 of public funds for every $1 spent. The total savings to taxpayers for the program (in constant 1981 dollars discounted at 3 percent annually) were approximately $28,000 per program participant.#31 According to the program evaluators, taxpayers saved approximately $5,000 in special education, $3,000 in crime, and $16,000 in welfare expenditures per participant. More Perry Preschool graduates enrolled in college or other advanced training, which added $1,000 per preschool participant's 30John M. Love and others, Study of the Home-Based Option in Head Start, RMC Research Corporation, 1988. 31Lawrence J. Schweinhart and David B. Weikart, "The High/Scope Perry Preschool Program," in 14 Ounces of Prevention: A Casebook for Practitioners. 38 costs; but due to anticipated increased lifetime earnings, the average preschool participant was expected to pay $5,000 more in taxes. The Yale Child Welfare Research Program also showed significant cost savings over time. Researchers estimated that 15 control families cost taxpayers $40,000 more in 1982 in welfare and school remediation expenses than did 15 home-visited families in a follow-up study conducted 10 years later. Families in the program showed a slow but steady rise in financial independence, which translated into reduced subsequent welfare costs. No significant differences were found for girls, but each participating boy required, on average, $1,100 less in school remedial services than boys in families who had not received services.#32 Few Comparisons of Cost-Effectiveness ------------------------------------- Cost-effectiveness analysis evaluates the cost of producing a particular outcome using alternative strategies. But the most effective or least costly alternative may not always be the most cost-effective.#33 We found only three cost-effectiveness analyses of programs that compared home visiting to other alternatives. In one case, providing home visiting was more cost-effective than providing longer hospitalization for low birthweight infants. In another case, using paraprofessional home visitors in conjunction with professional, center-based social work therapy was more effective in treating child-abusing families, but also more costly, than providing center-based social work therapy alone. A third case showed that providing home-based preschool services cost slightly less per child on average than center-based services, but resulted in equal outcomes. The New England Journal of Medicine reported that home visiting allowed one Philadelphia hospital to serve low birthweight infants more cost-effectively at home than in the hospital. Low birthweight infants were randomly assigned to one of two groups. Members of the control group were discharged according to routine nursery criteria, which included an infant weight of about 4.8 lbs. Those in the experimental group were discharged before reaching this weight if they met a standard set of conditions. Families of early-discharge infants received individualized instruction, counseling, and home visits, and were allowed to 32Victoria Seitz and others, "Effects of Family Support Intervention: A Ten-Year Follow-up," Child Development. 33Henry M. Levin, Cost-Effectiveness: A Primer, New Perspectives in Evaluation, Volume 4, Sage Publications (1983). 39 call a hospital-based nurse specialist with any questions for 18 months.#34 Early hospital discharge did not result in later problems, such as increased rehospitalizations, and proved to be more cost- effective than keeping infants in the hospital. The average hospital charge for the early discharge group receiving in-home services was $47,520 compared to $64,940 for the control group. The home-visited infants also experienced a 22-percent reduction- -$5,933 versus $7,649--in physicians' costs. Costs for the nurse home visits averaged $576 per child, compared to average additional overall hospital costs and physician charges of $19,136 per child for the comparison group of low birthweight infants retained in the hospital. Since 75 percent of the early discharged infants were on Medicaid, the program represented considerable public health cost savings. Another program evaluation studied the cost-effectiveness of adding home visiting by nonprofessionals to center-based professional social worker therapy to prevent child abuse and neglect. Families identified as abusive or potentially abusive were randomly assigned to either professional social work therapy services only or a combination of slightly fewer hours of social work therapy combined with home visiting. No families in either group were reported for abusing their children while in treatment. Only 26 percent of the home-visited families dropped out of treatment during 1 year, compared to 50 percent of the families receiving center-based services only. Overall, the home-visited families showed slightly improved outcomes compared to the group that received only center-based social work services.#35 However, in this case, combining home visiting with center-based social work services almost tripled the cost per client (from $93 to $255 per month). The increased costs were due to giving the home visitors low caseloads (average caseload was 6) and having a separate supervisor for the home visitors, rather than letting the social workers supervise home visitors. Program evaluators suggested that using nonprofessional home visitors could be more cost-effective if the caseloads were increased, full-time home visitors were used, and the home visitors were supervised by the 34Dorothy Brooten and others, "A Randomized Clinical Trial of Early Hospital Discharge and Home Follow-up of Very-Low-Birth- Weight Infants," New England Journal of Medicine, Vol. 315 (Oct. 9, 1986). 35Joseph P. Hornick and Margaret E. Clarke, "A Cost- Effectiveness Evaluation of Lay Therapy Treatment for Child Abusing and High Risk Parents," Child Abuse and Neglect, Vol. 10 (1986). 40 social workers. The evaluation did not analyze long-term costs or savings, such as the longer term significance of retaining more abusive or potentially abusive families in treatment. While some observers might assume that providing home-based services is likely to be more expensive than providing center- based services, this is not necessarily so. Head Start officials told us that Home-Based Head Start cost less per child in fiscal 1988 ($2,429) than did the average 1989 projected Head Start cost per child ($2,664). However, Head Start provides home-based services not because they are less expensive, but because they bring Head Start to rural children living in isolated areas who might otherwise not have access to a preschool program. 41 CHAPTER 4 --------- POOR PROGRAM DESIGN CAN LIMIT BENEFITS -------------------------------------- OF HOME VISITING ---------------- Not all programs using home visiting to deliver services have been successful. Some programs have not measurably improved maternal and child health, child welfare, and child development. Program evaluators do not always discuss the reasons for program failure. But when they do, the reasons are often tied to specific problems in program design and implementation. By analyzing the literature on home-visiting evaluations and consulting with home-visiting experts and program managers, we identified critical design components that should be considered when developing programs that use home visitors. POOR PROGRAM OUTCOMES LINKED TO DESIGN WEAKNESSES ------------------------------------------------- Some evaluations of programs using home visitors that failed to achieve desired outcomes have identified certain causes for the failure. These include -- failure to use objectives to guide the program and its services, -- poorly designed and structured services, -- insufficient training and supervision of home visitors, and -- the inability to provide or access the range of services multiproblem families need because the program is not linked to other community services. Several examples illustrate these problem areas.#36 36For additional evaluations of programs that were not successful at achieving some key objectives, but for which the causes of failure were not identified or discussed here, see: Earl Siegel and others, "Hospital and Home Support During Infancy: Impact on Maternal Attachment, Child Abuse and Neglect, and Health Care Utilization," Pediatrics, Vol. 66, No. 2 (Aug. 1980); Violet H. Barkauskas, "Effectiveness of Public Health Nurse Home Visits to Primarous Mothers and Their Infants," American Journal of Public Health, Vol. 73, No. 5 (May 1983); Richard P. Barth and others, "Preventing Child Abuse: An Experimental Evaluation of the Child Parent Enrichment Project," Journal of Primary Prevention, Vol. 8, No. 4 (Summer 1988). 42 Child and Family Resource Program --------------------------------- The Child and Family Resource Program, a federally funded demonstration project initiated by the Administration for Children, Youth, and Families, was an ambitious home-visiting program that had little impact on one of its two main objectives. Initiated in 1973, this 11-site, home- and center-based project was designed to strengthen families economically and socially and to improve child health and development. Paraprofessional home visitors helped families access needed social and health services, including basic education and job readiness training, and, through child development activities, taught parents to improve their parenting skills. The program improved mothers' employment and educational status. However, the program did not improve child health and development outcomes for the families randomly assigned to receive program services and only marginally improved parental teaching skills. Program evaluators identified three design and implementation weaknesses that contributed to the program's failure to improve child health and development. First, home visitors did not pay sufficient attention to all objectives when providing services; they spent most of their time counseling on the need for continued schooling, job training, and employment, instead of balancing this objective with training for parents aimed at improving child development. Although child development was a major program objective, the amount and frequency of child development services provided were low. Second, the quality of child development activities provided may have been inadequate. Home visitors tended not to demonstrate activities so that parents could learn by imitation. Third, program evaluators stated that inadequate training and supervision of home visitors contributed to the program's lack of success.#37 Boston's Healthy Baby Program ----------------------------- The HHS Inspector General reported in 1989 that Boston's Healthy Baby Program, an ongoing program, had similar weaknesses. The program's goal is to improve birth outcomes by preventing premature birth through health education by home visitors. The Inspector General did not address program effectiveness or collect complete data to determine whether program participation improved birth outcomes. However, the Inspector General reported 37Robert Halpern, "Parent Support and Education for Low- Income Families: Historical and Current Perspectives," Children and Youth Services Review, Vol. 10, (1988); Marrit J. Nauta and Kathryn Hewett, "Studying Complexity: the Case of the Child and Family Resource Program," in Evaluating Family Programs, Heather B. Weiss and Francine H. Jacobs, ed., Aldine de Gruyter, New York (1988). 43 that the program failed to accomplish four of its service delivery objectives. The program was doing little outreach to enroll the target population, was not consistently assessing risk factors among program participants, was providing services late in pregnancy and not emphasizing all necessary health information, and was not well coordinated with other programs. Many of the program's clients contacted by the Inspector General who had experienced poor birth outcomes, though assessed for risk, had never received program services or had received them only postnatally. The Inspector General attributed these problems to specific program design and implementation weaknesses. The program's objectives were not guiding the design and development of services. The home visitors were poorly trained and supervised. In addition, the program, serving families with multiple problems such as inadequate housing and substance abuse, was located in an agency with little experience in helping such families. The program staff also had not developed effective linkages with prenatal care providers and other social service agencies.#38 Rural Alabama Pregnancy and Infant Health Program ------------------------------------------------- The Rural Alabama Pregnancy and Infant Health Program, one of five Ford Foundation-sponsored Child Survival/Fair Start programs, had mixed success in meeting its objectives to improve birth outcomes, child health, and child development. This paraprofessional home visitor program improved the use of health care by low-income families, including adequate immunization of client children. But it did not significantly improve infant birthweights, infant health at birth, or infant development, compared to a demographically similar group of children who were not visited.#39 Program evaluators in 1988 reported three problems with the program. First, compared to other Child Survival/Fair Start programs, the Rural Alabama Program put less emphasis on becoming familiar with the chosen target population of low-income young women and their needs. The program was initially designed to have older, experienced paraprofessional women as home visitors, but found that younger home visitors could establish closer relationships and were more effective with young clients. Second, the program did not have a single structured curriculum 38Office of Inspector General, Department of Health and Human Services, Evaluation of the Boston Healthy Baby Program (July 1989). 39J.D. Leeper and others, "The Rural Alabama Pregnancy and Infant Health (RAPIH) Program," presented at the 1988 Annual Meeting of the American Public Health Association. 44 of information to teach the clients. Finally, program evaluators concluded that the home visitors needed more supervision.#40 Prenatal/Early Infancy Project ------------------------------ The Prenatal/Early Infancy Project in Elmira, New York, demonstrated impacts on birthweight, maternal health, reduction in child abuse, and improved maternal education or employment status when it was an experimental research program, but when the local health department took it over, the program was altered. As a demonstration project, the program had multiple sources of funding, including HHS, the Robert Wood Johnson Foundation, and the W. T. Grant Foundation. When the 6-year grant funding ended in 1983, the local health department absorbed the program, while changing its definition and extent of services, target population, and caseload per home visitor. As a result of these changes, all of the original home visitors left within a few months. One director of county services told us that the program was no longer achieving the same reductions in low birthweight as the original project. The program's absence of final evaluation data in 1983, reduced financial support, and location within the local health department all contributed to the changes. Some of these changes resulted from a reluctance to invest substantially in a program whose benefits had not yet been fully demonstrated at that time. But a difference in philosophy also prompted the change in program focus. Local officials told us there was not unanimous agreement with the research program's broad health and social service orientation and intensity. They also did not agree with limiting services to the target population of first-time mothers- -particularly low-income, unmarried teen mothers--even though these women were among the ones who benefited most from the experimental program. Local officials believed that some minimum level of home-visiting services should be provided to a larger group of pregnant women, which may be diluting the overall impact of the formerly targeted, high-intensity services. 40Mary Larner, "Lessons from the Child Survival/Fair Start Home Visiting Programs," presented at the 1988 Annual Meeting of the American Public Health Association; J.D. Leeper and others, "The Rural Alabama Pregnancy and Infant Health (RAPIH) Program," presented at the 1988 Annual Meeting of the American Public Health Association; M.C. Nagy and J.D. Leeper, "The Impact of a Home Visitation Program on Infant Health and Development: The Rural Alabama Pregnancy and Infant Health Program," presented at the 1988 Annual Meeting of the American Public Health Association. 45 CRITICAL COMPONENTS FOR PROGRAM DESIGN -------------------------------------- Our analysis of these and other evaluations, consultation with experts, and interviews with federal, state, and local program officials point to the importance of sound program design. Further, evidence from these sources suggests that certain program design components are critical to success. Programs using home visiting as an early intervention strategy can be successful at achieving their objectives if program designers and managers recognize the interplay among these critical components. Information on the success and failure of programs using home visiting can be found in the education, health, and social support literature. Yet we could find no cross-discipline synthesis or analysis of the reasons for these varied outcomes. While no single approach exists for designing successful programs, we have identified critical design components with associated characteristics that appear to be important when designing and implementing programs that use home visiting as a service delivery strategy. These key components include -- clear and realistic objectives with articulated program goals and expected outcomes, -- a well-defined target population with identified service needs, -- a plan of structured services designed specifically for the target population, -- home visitors trained and supervised with the skills best suited to achieve program objectives, -- sufficient linkages to other community services to complement the services that home visitors can provide, -- systematic evaluation to document program process and outcomes, and -- ongoing, long-term funding sources to provide financial stability. In operation, these components are not independent of one another. They must work in harmony, as part of an overall program design framework. The next chapter describes in more detail a framework that we developed to guide program design and management. In addition, we illustrate, through case studies, how programs with varying objectives, services, and types of home visitors used these critical components to strengthen program design and operation. 46 CHAPTER 5 --------- A FRAMEWORK FOR DESIGNING PROGRAMS ---------------------------------- THAT USE HOME VISITING ---------------------- Home visiting evaluators, experts, and managers point to certain common characteristics among diverse program designs as prerequisites to achieving program goals. To illustrate how these characteristics can be used as a framework in designing and operating programs using home visitors, we reviewed eight programs operating in the United States and Europe that appeared to be successful in meeting their stated objectives. (See app. I for more detailed information on these programs.) These eight programs commonly used home visitors to deliver services, yet varied in other ways. They differed in objectives, in the group they targeted for services, and in the types of services provided. Some operated in rural areas, others in urban areas. Some used professionals, such as registered nurses and social workers, while others used non-college-educated paraprofessional community women. (See table 5.1 for highlights of differences.) Despite these differences, these programs illustrate the importance of certain design characteristics. In general, these programs' managers -- developed clear objectives, focusing and managing their operations accordingly; -- planned service delivery carefully, matching the home visitor's skill level to the service provided; -- worked through an agency with both a health and social support outlook to provide families with a variety of community resources either directly or by referral; and -- developed strategies for ongoing funding to sustain program benefits over time. From these characteristics, we developed a framework for developing and managing programs that use home visiting. The framework's constituent parts, shown in Figure 5.1, include clear objectives, structured service delivery procedures, integration into the local service provider network, and secure funding over time. 47 Table 5.1: Characteristics of United States and European Programs GAO Visited Program Area Population Type of name served served home visitor#a ------- ------ ----------- ------------ United States ------------- Resource Mothers Rural Pregnant teens, Paraprofessional for Pregnant teen mothers Teens, South Carolina Center for Urban Developmentally Professional Development, delayed children Education, and Nutrition (CEDEN), Austin, Texas Changing the Urban Pregnant low- Professional Configuration income women of Early Prenatal Care (EPIC), Providence, Rhode Island Southern Seven Rural Pregnant teens Professional Health Department, Southern Illinois Maternal and Child Urban Pregnant Paraprofessional Health Advocate women; mothers Program, with high-risk Detroit, Michigan newborns Roseland/Altgeld Urban Pregnant teens; Paraprofessional Adolescent Parent teen mothers Project (RAPP), Chicago, Illinois Europe ------ Great Britain Nationwide All newborns Professional Health Visitor Denmark Infant Nationwide Newborns#b Professional Health Visitor 48 aProfessional includes individuals with postsecondary degrees in either a specialized area, such as nursing, or a broader field, such as early childhood education or social work. Paraprofessional includes individuals with no postsecondary certification or specialized training. bAll newborns in municipalities that hire home visitors (90 percent of all newborns). Figure 5.1: Framework for Designing Home Visitor Services Clear Program Objectives Objectives, clients, and services are interdependent Objectives as a management tool Structured Program With Appropriate Home Visitor Skills Structured service delivery plan Home visitor skills matched with services Training and supervision tailored to home visitor needs Comprehensive Focus With Strong Community Ties Services linked with other local providers Agency supports multifaceted approach Secure Funding Over Time Plan for program continuity CLEAR OBJECTIVES AS A CORNERSTONE --------------------------------- Clear, precise, and realistic objectives are crucial for enabling programs using home visiting to sustain program focus among the home visitor staff and to deliver relevant services to an appropriate client population. Developing such objectives forms the foundation for determining specific services and identifying the target population. Well-articulated objectives also allow programs to develop outcome measures for monitoring progress. Objectives, Target Populations, and Services Are Interdependent --------------------------------------------------------------- Objectives, target populations, and services are logically interconnected program elements. As program managers develop objectives in response to problems, such as infant mortality or child abuse, they also begin to identify the client needing help and the type of services that will suit the client. The Center for Development, Education, and Nutrition (CEDEN), for example, developed a program using home visiting to address an expressed local need. It was created in 1979 in response to a survey of families in East Austin, Texas, that identified delayed child 49 development as a pressing community problem. To address children's developmental delays, program managers selected as a target population children most likely to benefit from program services--those under age 5, with an emphasis on those under age 2. This selection was based not only on the expressed need of the community, but also on an assessment of those most likely to benefit from the proposed services--in this case, very young children, who are more responsive than older children to measures for preventing and reducing developmental delay. Program managers must be realistic in developing objectives and services. In some instances it may not be possible--or practical--to meet the needs of all the program's target population, especially those at highest risk. Roseland/Altgeld Adolescent Parent Project (RAPP) in Chicago helps pregnant and parenting teens with parenting skills and self-sufficiency. The program does not accept certain members of its target group who have severe problems, such as mental or emotional disorders or substance abuse. Program officials do not think these women would benefit from the program because the program services are not intense enough to help them. RAPP refers women with these problems to other programs. The program also does not serve teens who have strong family support and who function well independently. In program