State Policy Action Team Meeting
Integrating Quality Home Visiting in State Early Childhood Systems
Chicago, Illinois
June 6-8, 2012
In June 2012, seven state teams came together in Chicago, Illinois, with representatives from the
ZERO TO THREE Policy Center; the Maternal, Infant and Early Childhood Home Visiting
Program Technical Assistance Coordinating Center (TACC) at ZERO TO THREE; the Pew
Home Visiting Campaign; the Center for Law and Social Policy (CLASP); and the U.S.
Department of Health & Human Services Health Resources and Services Administration
(HRSA) to discuss ways that quality home visiting services could be integrated in state early
childhood systems. State teams represented Connecticut, Georgia, Michigan, Nebraska, New
Mexico, Ohio, and Oklahoma. The meeting was generously supported by funding from the Birth
to Five Policy Alliance and the Pew Home Visiting Campaign.
The goals of the meeting were to:
• Highlight innovative state models and strategies for integrating quality home visiting
services in state early childhood systems.
• Assist participating states in moving forward in integrating quality home visiting in their
developing early childhood systems so that more infants and toddler receive high-quality
services.
• Promote relationships and continued collaborative work among participants.
The sessions at the meeting were planned around these goals. In addition to state team members
and national organization staff, there were several invited presenters to round out the expertise,
including:
• Audrey Laszewski, The Early Years Home Visitation Outcomes Project of Wisconsin
• Gaylord Gieseke, Voices for Illinois Children
• Mary Martin, Colorado Department of Public Health and Environment
• Nancy Keel, Kansas Parents as Teachers Association & Kansas Early Learning
Collaborative
• Steffanie Clothier, National Conference of State Legislatures and the Birth to Five Policy
Alliance
• Sunday Gustin, New Jersey Department of Children and Families
Review the meeting agenda here.
Large Group Session
Integrating Home Visiting in Collaborative Early Childhood Systems
Presenters:
• Barbara Gebhard, ZERO TO THREE Policy Center (facilitator)
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Gaylord Gieseke, Voices for Illinois Children
Mary Martin, Colorado Department of Public Health and Environment
Session Key Points:
• Relationship-building on both the local and state levels is key to establish collaboration
from the beginning, but that should also be embedded into ongoing structures (with a
common vision like the CO early childhood framework). Having home visiting as a
subcommittee of the Early Childhood Advisory Council or another state-level council
seems to be an important element.
• New funding can help “grease the skids” for developing system infrastructure, such as
data systems and common standards.
• Messaging around common goals, such as school readiness, can help build cross-agency
support for home visiting within an early childhood system.
Full Session Notes:
Barbara Gebhard opened the session by describing two models for comprehensive early
childhood systems.
• The ZERO TO THREE policy agenda: all children need good health, strong families, and
positive early learning experiences. Services must be high quality, culturally responsive,
accessible and affordable to all children and families who need them. They must be
supported by an infrastructure with regulations and standards, quality improvement,
professional development, accountability and evaluation, public engagement, political
will-building, governance and leadership, and financing. Together the services and
infrastructure make a system.
• The revised Early Childhood System Work Group ovals graphic: thriving children need
comprehensive services that promote children’s physical, developmental, and mental
health; nurturing relationships, safe environments, and enriching experiences that foster
learning and development; and resources, experiences, and relationships that strengthen
families, engage them as leaders, and enhance their capacity to support children’s wellbeing. Functions of a comprehensive early childhood system include: define and
coordinate leadership; finance strategically; enhance and align standards; create and
support improvement strategies; ensure accountability; and recruit and engage
stakeholders.
She also shared two home visiting tools the Policy Center has released:
• Key Components of a Successful Early Childhood Home Visitation System: A SelfAssessment Tool for States – Helps states assess how well their system addresses eight
core components of a home visitation system.
• Home Visiting Community Planning Tool – Helps communities identify strengths/needs,
explore existing services/gaps, choose a home visiting model that meets their needs, and
analyze implementation issues.
The state presenters (CO and IL) then answered a series of questions about system-level work in
their states, community engagement, and messaging.
Colorado
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The early childhood system in Colorado has primarily been an early learning system.
Home visiting has been challenged to have a full seat at the table. MIECHV has been
helpful in addressing this.
Colorado created an early childhood framework. Home visiting contributes to the
framework in most places. The framework is truly the rallying point for early childhood
systems work. Whenever making decisions about anything, Colorado goes back to the
blueprint in the framework.
The framework was developed by a diverse group of stakeholders that included all
relevant state agencies. The work was spearheaded by the lieutenant governor’s office.
The home visiting work in Colorado had been organized through a home visiting
coalition that started in the late 1980s - a privately organized collaboration
Colorado designed a process for identifying communities at risk and engaging with them
in the planning of MIECHV investments. The work was coordinated through local Early
Childhood Councils (ECC). ECC’s are the lead agencies at the community level to
develop home visiting plans and make recommendations. Colorado used the ZTT
community planning tool.
o Local ECCs were a pilot project for a long time, but as systems work matured
they grew. Now almost every county (or group of counties) has an ELC and
coordinator. They vary in terms of effectiveness, so the state has to adjust its
approach to each ECC. They get ECC grants from CCDBG. ECC’s include
providers, law enforcement, business, community leaders, parents, and others.
Colorado is giving $20k systems-building contracts to local councils in communities
where MIECHV home visiting is being expanded to help identify activities that will
connect home visiting with other services in communities and better coordinate all early
childhood services.
Colorado’s internal messaging focus is around aligning early childhood systems. The
rallying cry has been school readiness and literacy. Home visiting fits into a lot of slots,
but this one resonates. Having babies born healthy and promoting good parenting and
child development lead to school readiness.
The Early Childhood Leadership Commission wants to do more formal messaging to
build support for legislation, universal preschool, and other large efforts.
Illinois
• The state has been working in a public/private collaborative environment in early
childhood for 20+ years, and home visiting came into the state very early.
• Early 1990’s legislation created a Healthy Families program and Parents Too Soon (a
model administered by the Ounce of Prevention Fund). By the mid 1990’s, there were
line items in the state budget for home visiting, and Illinois now has $20 million in
HF/PTS state funding combined. There is additional state money supporting Parents As
Teachers. In the mid-1990’s, Illinois created its early childhood block grant, which
includes a birth-to-three set-aside (minimum of 11%). This set-aside can only be spent on
a handful of evidence-based home visiting models.
• In 2003, Illinois created its Early Learning Council, which is now in the governor’s
office. Every standing committee has one or two outside-of-government co-chairs and
one public co-chair. Illinois created a home visiting task force as a standing committee of
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the ELC to embed home visiting into the broader system and to create a place for
dialogue and planning for federal funding.
Illinois has three leading advocacy organizations. There is strong collaboration between
them and with state agencies – this dedication to collaboration has been key.
Illinois is currently working on a TQRIS. The system will be for pre-k and child care –
any group settings. Home visiting will not be rated because most home visiting programs
have national standards and IL plans to tighten up on those, but not create another process
for them.
Illinois is supporting community work through MIECHV. The focus is on a combination
of expanding home visiting in the selected communities and working on local level
challenges to building an integrated cross-systems structure.
High-risk communities were invited to provide proposals to receive MIECHV funds. The
proposals had to be completed by an existing early childhood collaborative. They could
choose from four home visiting models (Parents as Teachers, Healthy Families, Early
Head Start, and Nurse Family Partnership), in any combination, and had to select a lead
agency to coordinate and oversee collaboration. Communities are also required to:
establish universal screening and intake for every pregnancy and birth, assess family
needs, and make referrals through an effective referral system that includes other services
as well as home visiting. This required lots of additional partnership-building,
particularly with public health at the community level.
Illinois has a Birth to Three Training Institute at Ounce, which trains across all early
childhood home visiting models.
The Early Learning Council frames everything in terms of early learning and school
readiness and Heckman (return on economic investment). Trauma messaging is also
really helpful. Bruce Perry has emphasized that above all to prevent and respond to
trauma it’s about the relationship, and home visiting is about the relationship.
Illinois is engaging 6 MIECHV communities in framing a set of social marketing
awareness strategies, first targeting teen moms, about how to think differently (seeing
asking for help as a positive and good for the community) and create a community
cultural norm that supports parents.
Resources:
• Session PowerPoint Integrating Home Visiting in Collaborative Early Childhood Systems
• ZERO TO THREE’s Key Components of a Successful Early Childhood Home Visitation
System: A Self-Assessment Tool for States
• ZERO TO THREE Home Visiting Community Planning Tool
• Colorado’s Early Childhood Framework
• Illinois’ Early Learning Council Structure
Concurrent Session
Developing a Continuum of Home Visiting Services
Presenters:
• Maria Gehl, MIECHV Technical Assistance Coordinating Center at ZERO TO THREE
(facilitator)
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Sunday Gustin, New Jersey Department of Children and Families
Mary Martin, Colorado Department of Public Health and Environment
Session Key Points:
• There are many reasons to link services into a continuum: to serve families for a longer
period of time, to provide greater depth and range of service options, or to create
efficiencies.
• The purpose of a continuum is to effectively serve families and link them to services, not
to foster competition or decide which model is best.
• MIECHV has been the catalyst for work on developing a continuum in many states.
Full Session Notes:
Maria Gehl opened the session by introducing the concept of a continuum.
• Services must work in conjunction with infrastructure.
• Defining “home visiting services,” “continuum,” and “development” for your state is
important.
• Chapin Hall is leading the model developers group. They have been discussing the
continuum:
o Not limited to MIECHV programs.
o Lots of ways to link: to serve families for a longer period of time, for greater
depth of services, or to create efficiencies such as common training.
• MIECHV has been the catalyst for development of a continuum and system integration in
many states.
Each of the state presenters then gave an overview of their work related to creating a continuum.
Colorado
• Built on services that already existed—5 models.
• Ranked 15 communities based on assets as well as risk to choose those that would
receive MIECHV funding.
• ZTT community planning tool helped communities look at data, but balanced with
respecting programs that already existed.
• Have difficult conversations among models at the state level so will be more aligned in
working with communities.
• Have not yet moved to discussion of central intake.
• Extent of coordination is variable at the community level.
• Works with state intermediaries for the models to provide training, technical assistance,
and data collection to programs
New Jersey
• Healthy Start grants provided impetus to test ideas at the community level.
• Had Healthy Families America through child welfare funding for many years.
• NJ Task Force on Child Abuse and Neglect’s prevention subcommittee recommended
broadening the models.
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Beginning in 2007, funded Nurse-Family Partnership and Parents as Teachers with new
state funding.
Concentrated resources on prenatal to age 3.
Purpose is to effectively serve families and link them to services, not to decide which
model is best.
In 2008, sponsored a home visiting meeting to discuss how models might fit into a
continuum. 6 regional groups began to envision a continuum in their areas.
Central intake is not yet statewide but will be developed through the competitive funding
and our collaboration with the Department of Health.
The presenters and session participants then engaged in discussion around a number of
questions:
• Where does Early Intervention fit?
o NJ: Early Intervention is an important component of the continuum. In NJ,
relationships with EI have been strengthened since our planning work for the
Early Learning Challenge application. This led to a successful application as a
National Help Me Grow affiliate that will help NJ promote earlier identification
of developmental delays and appropriate referral of children for Early
Intervention. And, ensure coordination (not duplication) between Home Visiting
and Early Intervention services.
o CO: Early Intervention and infant mental health are involved in state-level
planning.
• Is anyone working on home visiting as differential response for child welfare?
o OK, OH, GA, and CT are working on this.
• How is Early Head Start integrated into the continuum?
o NJ: 13 of 21 counties have EHS home-based services. New Jersey has been
working with the Head Start State Collaboration Director to hold joint planning
meetings with EHS providers to ensure that existing Home-Based sites are
integrated into the NJ system so that children are not enrolled in multiple models.
o The model developers group has discussed enrollment in dual models, which
varies in appropriateness. For example, Child FIRST can be used with other
models.
o CO: The Head Start Collaboration Director is on the home visiting stakeholders
group. EHS home-based programs must use the Parents as Teachers curriculum to
be funded through MIECHV.
• How do programs avoid duplication of services?
o OH: The community hub model tries to avoid duplication in care coordination.
They are also trying to regionalize.
o CT: Child FIRST builds on plans for the family developed by other programs.
• What strategies encourage model fidelity?
o NJ: Strengthen technical assistance to local programs as well as monitoring.
o CO: CQI modeled off the Nurse-Family Partnership process.
o HRSA: Ongoing feedback between programs and states for collective learning.
o TACC: Capacity-building for CQI at the community level.
o CT: Metric data used in Child FIRST to learn from and share in a learning
collaborative among program sites.
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How do states deliver services to TANF mothers who are working?
o CLASP: New resource on connecting home visiting to family, friend, and
neighbor care.
o NJ: Contracts require visits outside traditional work hours, as needed.
o CO: Nurse-Family Partnership is doing research on whether outcomes can be
maintained with a different visit schedule.
Concurrent Session
Building a Professional Development System for Home Visiting Staff
Presenters:
• Kathleen Strader, MIECHV Technical Assistance Coordinating Center at ZERO TO
THREE (facilitator)
• Amy Bunnell, Nebraska Department of Health and Human Services
• Jesse Leinfelder, New Mexico Children, Youth and Families Department
• Soledad Martinez, New Mexico Children, Youth and Families Department
Session Key Points:
• A comprehensive professional development system is key to achieving program fidelity
and positive outcomes for families.
• Regardless of how many models are being implemented in a state, there is value to
having core curriculum or training in which all home visitors participate to ensure they
have the same basic level of skills and competencies.
• States are still struggling with how to incentivize higher levels of professional
development because compensation often isn’t tied to the professional development
system.
Full Session Notes:
Kathleen Strader opened the session by describing the link between staff retention, family
retention, and program and child outcomes. Research has shown that caregiver continuity
positively affects program and child outcomes. She noted the importance of a comprehensive
professional development system for achieving program fidelity and described the professional
development system as a triangle with three vital components that build on each other:
• leadership capacity
• competency drivers (selection of staff, training, supervision, coaching)
• organization drivers
Alignment between community and state professional development strategies is key.
Each of the state presenters then discussed steps their states are taking to build professional
development systems for home visiting staff.
New Mexico is doing several things to build an integrated professional development system.
• The state has an articulated higher education system for early childhood with multiple
entry and exit points including an 11-credit ECE certificate, a 29-credit program
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certificate, an associate’s degree, and a bachelor’s degree. Many of the classes are
available online.
o There are three specializations: teacher education (birth-3 and ages 4-8, plus
teacher licensure); EC program administration; and family infant toddler
specialist (the infant mental health competences are embedded in this track which
was originally designed for early intervention staff and home visitors).
o Some of the challenges to implementing this system include: access and demand;
funding; and a lack of reward for early intervention and home visiting staff to take
the IT track – there needs to be an incentive or system driver to increase the
number of people participating.
New Mexico has also expanded professional development specifically for home visiting.
• They started by focusing on training staff on data management. Home visitors are
entering their own data so it is essential that the data they enter is correct and that doing
so isn’t seen as an additional burden, but as intrinsic to the work they are doing with
families.
o All managers and directors participated in the revision to the data management
system. It really paid off – staff are using data on drop-out rates to identify why
things are happening – led to a recognition that training for staff on family
engagement is important.
o Embedded in this training was a shift from a case-management focus to parentchild interactions. Case management is still important, but home visitors
understand that it is not the primary function of their job. Rather than focusing on
the adult and what is missing from the home, they now focus on the child.
• Key components of the home visiting professional development system include:
o Reflective supervision – The state has a contract with the university to provide
supervision to program directors once a month. They also send articles on things
like attachment, risk, and trauma. The supervisors are endorsed at level 3 or 4 of
the Michigan Infant Mental Health Competencies. Putting reflective supervision
in place has had a positive impact on staff retention.
o Relationship-based – Home visitors are trained on the relationship-based work
and on how to educate parents about the importance of building strong
relationships with their children. Relationships are the foundation for brain
development and school readiness.
• The state requires core home visiting training focusing on the foundations of relationshipbased home visiting. There are four modules that cover topics such as: basic skills, use of
screening tools, self-awareness, and family expertise. The modules are offered on-site
and online. The IMH competencies are embedded in them.
• New Mexico recently started a mentor-to-mentor program for home visitors and plans to
use video-taping of home visits to inform reflective supervision.
• The state holds an annual conference for home visitors, domestic violence program staff,
EHS staff, and Part C staff – about 400 people attend.
• New Mexico was one of the first states to adopt the Michigan Infant Mental Health
competencies. The state has one of the highest numbers of people who have achieved
endorsement. Unfortunately, there are no financial incentives for doing so.
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Nebraska recently released a Home Visiting Core Practices and Principles Online Training
program, which provides information and resources that all home visitors can use.
• The training consists of seven core modules designed to provide home visitors with the
foundation for working with parents in the home. They focus on topics such as effective
communication, family systems, cultural competency, observation and documentation,
and care of self.
• Activities are embedded in the training, many of which require the home visitor to work
with their supervisor, creating an opportunity for reflective supervision.
• The training is available at no cost to anyone who is interested, including parents and
people outside the state. Users can obtain certificates for individual modules or for
completing the full training program.
• The training was developed over the course of about a year using Part C ARRA funds.
Most of the curriculum and content for the modules was adapted from an existing 6-day
face-to-face training already being offered in the state.
• The online format was pursued in response to hearing from home visitors that the inperson training was too difficult to attend because of the time commitment and fees
required.
• A cross-agency stakeholder group, which also included private home visiting funders, led
the work to develop and disseminate the self-paced training program.
• Part C Early Intervention staff began piloting the training program in April 2012.
Feedback so far is very positive. Part C home visitors are now required to complete the
full training program (with an 80% pass rate on all quizzes) within 3 months of being
hired.
• Sixpence requires that its funded home visiting programs use home visiting modules.
They do their own training too, but this entry-level information is built upon.
Nebraska is also in the process of developing Early Childhood Integrated Skills & Competencies
for Professionals. The state previously had competencies for early care and education, but
wanted to expand them to include infant mental health and home visiting.
• A group of practitioners was brought together to discuss the early care and education
competencies that touch on infant toddler mental health. They started cross-walking the
two to see how they would align. The idea for developing universal competencies (which
include early care and education, infant mental health, and home visiting) grew out of this
work.
• The resulting document contains 11 universal competencies for best practice that relate to
all three disciplines. Using a table format, there are three columns to the right of the
competencies that represent the interpretation of that universal competency in each
discipline. The intent is to demonstrate that universal competencies are relevant to the
work of the three disciplines but may look different in practice.
• Everyone uses different terminology so getting agreement on definitions and language
was very important.
• A draft of the Skills and Competencies was shared at the meeting. It is currently being
shared with people in the field through focus groups to obtain feedback. So far they have
been very well received. People like that they are cross-discipline.
• Once the Skills and Competencies are finalized, they will be embedded into the
professional development system.
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The core early care and education competencies still exist and are much more extensive.
These new ones only contain the competencies that fit into the integrated framework.
Resources:
• New Mexico’s PowerPoint New Mexico’s Efforts to Support Home Visitor Competence
• Draft of Nebraska’s Early Childhood Integrated Skills & Competencies for Professionals
• Nebraska Home Visiting Partnership’s Outline of Home Visiting Core Practices and
Principles Online Training
• Nebraska Home Visiting Core Practices and Principles Online Training
Large Group Session
Collecting Common Outcome Data across Home Visiting Models
Presenters:
• Karen Kavanaugh, Pew Center on the States (facilitator)
• Audrey Laszewski, The Early Years Home Visitation Outcomes Project of Wisconsin
• Sunday Gustin, New Jersey Department of Children and Families
Session Key Points:
• Collaboration with local project sites (providers and models) is key to developing
common outcomes and data collection processes that are sustainable and meaningful.
• Efforts to develop outcomes that a state wants to measure across models takes a great
deal of time and technical assistance to make sure local communities have the
infrastructure (technology resources in particular) and capacity (training and staff time) to
participate.
• Both the Wisconsin project and the state of New Jersey use one or more indicators to
track outcomes. States should focus the scope of outcomes on areas that home visiting is
proven to impact, and recognize they cannot measure everything.
Full Session Notes:
Audrey and Sunday presented on their states’ efforts to collect common outcome data.
The Wisconsin Early Years Home Visitation Project started in 2011 due to the need for better
accountability. It is housed within the Children’s Hospital and Health System. Over the last 10
years, those involved have built a collaborative project to measure outcomes across home
visiting models, using a “bottom-up” approach.
• The overall goal of the project is to provide a common outcome measurement process
and support its use in home visiting programs throughout Wisconsin.
• Ten programs participate voluntarily, with 876 children enrolled in these sites.
• The project uses Wisconsin’s public health data system (SPHERE) for its data
collection—a partnership that made the Outcomes project possible. Home visitors have
tablet PCs to use for screening. They function separately from the Internet, and data are
automatically sent to SPHERE.
• Building trust was vital to the success of the project. Bringing stakeholders together to
determine common outcomes was rooted in critical thinking on outcomes, indicators,
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measurement tools, and best practice. The group’s work has created a way to speak with
a common voice about home visiting.
Key milestones include:
o Stakeholders agreed on outcomes.
o The group determined a decision-making process—“I can live with it, and I can
support it.”
o Common screening tools were selected. This step was challenging, but working
with the group facilitated broad buy-in. The state is requiring some of the same
measurement tools for the programs they fund.
Key project successes include:
o Shifting from competitive mindset to a collaborative one.
o Programs have come to embrace data collection and the power it gives them to
grow and improve.
The project developed five core outcomes.
o Each outcome has at least one indicator.
o These outcomes do not capture all possible outcomes; rather, they focus on what
home visiting can affect within the early childhood system.
o Valid and reliable screening tools are vital to collecting meaningful data.
A metaphor for ensuring quality data is a three-legged stool:
o Leadership needed to embrace data collection and quality improvement efforts
o Local organizations needed help with resources, support, and building a culture
that recognize the value of data.
o Systems and technology are necessary. The project helped programs secure
funding to upgrade their technology infrastructure.
Next steps:
o Project leaders are developing a quality assessment tool that looks across domains
and models to assess overall program quality and guide program improvement
efforts.
o The project would like to grow statewide, as well as assist other states.
Conclusions and lessons learned:
o Significant training and technical assistance were required to ensure the project’s
success. Getting “quality data” took time and effort—states must think on a
practical level about what collecting outcome data means to make sure they have
the capacity to collect and support data collection and analysis in a meaningful
way.
o Strategic partnerships have been paramount to success—residing within CHHS
has been a major asset.
o Sites participate because the project helps them tell a collective story about home
visiting. They are able to speak in their communities about what they’re achieving
for families. Sites with strong data experienced a culture shift—data became an
important tool for celebrating success and driving community interest and
investment.
o The Outcomes Project has moved the public health field to focus much more on
outcomes than on processes—“spillover effect.”
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The New Jersey home visiting initiative began with an exploration of home visiting models
already operating in the state and an analysis of unmet need. A workgroup of state agency staff,
model developers, funders and advocates came together to look at their common goals and to
develop common outcomes. The state now has five evidence-based models in operation (NFP,
HFA, PAT, EHS and HIPPY) and focuses primarily on the prenatal to three age range.
• Performance targets are measured at three levels:
o Process measures, such as: time of enrollment.
o Impact objectives, such as: enrollment in WIC and insurance coverage
o Outcome objectives, such as: breastfeeding rates; pregnancy spacing; parent-child
interactions/abuse and neglect rates; early literacy; and family self-sufficiency.
• Some models were not accustomed to the state’s new performance target requirements
and have had to adjust. However, if a data element doesn’t apply to a model, e.g. HIPPY
does not have prenatal measures, they don’t have to report it.
• After determining the target populations and outcomes, the next step for the state was to
put in place a process to collect the data.
• New Jersey recently integrated home visiting objectives into a new quarterly report
format, with the aim of strengthening the CQI function of data.
• One advantage of a state-funded network is that it creates contracts with local
communities that include data expectations.
• To look collectively at impact and outcomes, programs need to be at capacity. Their time
should be spent on service delivery, not outreach. A strong central intake and referral
system is paramount.
• The goal of New Jersey’s outcomes system is to improve quality across models, for all
the populations they serve. The use and analysis of standard data reporting elements is an
important aspect of CQI and an effective way to provide ongoing feedback to home
visitors—and to celebrate their success.
Resources:
• Audrey Laszewski’s PowerPoint: Measuring Common Outcomes
• The Early Years Home Visitation Outcomes Project of Wisconsin 2010 Outcome
Attainment Report
• Sunday Gustin’s PowerPoint: NJ Home Visiting Initiative Developing Common
Outcomes For Multiple EBHV Models
• New Jersey DCF Division of Prevention and Community Partnerships’ EBHV Quarterly
Progress Reporting Form
Large Group Session
Leveraging Existing Funding Sources to Support a Strong Home Visiting System
Presenters:
• Barbara Gebhard, ZERO TO THREE Policy Center (facilitator)
• Wendy Grove, Ohio Department of Health
• Kathleen Feller, Nebraska Children and Families Foundation
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Session Key Points:
• Braiding is difficult, but more realistic than blending funds.
• Medicaid is not a silver bullet! There are a lot of considerations, which require extensive
technical assistance. Each state is different.
• Private support and involvement can enhance accountability.
Full Session Notes:
Barbara opened the session by giving an overview of various financing strategies for home
visiting, including blending and braiding different sources.
• Blending different sources: the end product becomes a new funding source with distinct
use and reporting criteria. Blending funding is difficult and much less acceptable.
• Braiding different sources: the end product retains the distinct eligibility and reporting
criteria of each of the sources. More dexterity and much more acceptable.
o There are challenges and opportunities associated with braiding funding including
obtaining approvals, sustaining funding, maintaining accountability, and
overcoming interagency turf considerations.
• The upcoming “fiscal cliff” and federal sequestration may make some sources of funds
unavailable for home visiting programs as states will face substantial reductions if
sequestration is implemented.
• A variety of public funding sources are potentially available for home visiting (use can
depend on specific state requirements/plans): Medicaid, TANF, Title V Maternal and
Child Health Block Grant, Social Services Block Grant, Child Abuse Prevention, General
Funds, and Master Tobacco Settlement Funds.
• Philanthropic funding can assist in elevating the program.
• Opportunities include collaborative cross-training of providers, coordinated family
recruitment and centralized intake, and leveraging private funding.
• Some states are using flexible revenue sources to fill in system gaps that are more
difficult to fund and sustain.
Given Medicaid’s mission, there has been increased interest in tapping into this funding stream
to sustain home visiting programs. But it is not a silver bullet.
• There are various Medicaid financing mechanisms that are potential sources for home
visiting services including: Targeted Case Management, Administrative Case
Management, Enhanced Prenatal Benefit, Managed Care, and Traditional Medicaid
Services.
• Other potential Medicaid financing mechanisms: Section 1905a Preventive Services,
Early Periodic Screening, Diagnosis, and Treatment, Section 1915b Freedom of Choice
Waiver.
• Medicaid can be braided with other revenue sources to fund programs.
• Highly technical and requires significant analysis before making a decision to pursue a
state plan amendment to the Center for Medicaid Services for review. The process also
requires the participation of several different stakeholders.
Wendy and Kathleen then discussed how their states have leveraged funding for home visiting.
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Ohio recently got a Medicaid state plan amendment approved to use Medicaid funds to pay for
some home visiting services.
• Ohio began working on the state plan amendment in August 2010; it was approved in
March 2012, and they hope to have it implemented by October, 2012
• The state had to switch from allocating funds to counties to direct provider agreements
and a reimbursement system for funding.
• The state is using an outside claims processing vendor.
• The billing mechanism is built into the existing data system. Home visitors enter
activities by child in 15 minute increments and the system figures out what is charged to
Medicaid. The data system synchs with the Medicaid enrollment list every 24 hours.
• The biggest challenge has been figuring out which activities are paid by Medicaid and
which are not. For example, Medicaid will not pay for doing assessments, but it will pay
for preparing to do assessments
• For now, Ohio is using Targeted Case Management
• The state initiated a service provider application process to ensure providers are high
quality – every application must have two letters of support from each county they want
to serve.
• Lessons learned:
o The same words might be used for different things – for example Ohio initially
thought they could bill Medicaid for assessments, but “assessments” meant
something different to Medicaid than to home visiting. It is important to discuss
these definitional issues early.
o Initially the state thought 60% of services would be Medicaid reimbursable; in
fact, the percentage will be lower.
o Calculating rates has been the biggest challenge.
o There was a steep learning curve on both sides
• It is important to remember that Medicaid works differently in every state, so states
cannot take a model used somewhere else and just apply it– individual analysis and
negotiation will be required.
Nebraska uses private funding to support some home visiting services. The Sixpence Early
Learning Fund is a public-private partnership that is used for grants to school districts to provide
programs and services for infants and toddlers who are most at risk of school failure.
• $20 million from the private sector is combined with a $40 million state investment. The
earnings of the combined fund are used to grant awards to community programs.
• The fund is overseen by the NE Early Childhood Education Endowment Fund Board of
Trustees, which represents public and private interests
• Grants are awarded to school districts in partnership with community-based programs
who meet quality standards set by the Board. Grant recipients must match at a minimum
50% of the total program costs through existing state and federal funds – local public
school and private contributions can be used.
o The community match is about $2.5 million annually.
o If grantees continue to meet evaluation targets, they continue to receive funds.
• In the 2010-2011 program year, Sixpence funded 13 programs across 11 school districts
in Nebraska to provide evidence-based services to young children (birth through age
three) and their families.
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o The funded programs were based on one of three models: family engagement
services, center-based infant/toddler care, or a combination of family engagement
and centered-based services.
o This was the third year of funding programs.
Lessons learned:
o The success of the Nebraska initiative would not be possible in the current
environment given fiscal challenges and political polarization. An analysis of the
ripeness for seeking private funding is essential.
o Have to be clear on goals and outcomes and be able to measure progress.
o Be inclusive.
Resources:
• Kay Johnson’s PowerPoint (presented by Barbara Gebhard) Blending and Braiding
Funds to Support Home Visiting Programs
• Wendy Grove’s PowerPoint Medicaid and Home Visiting
• Nebraska Early Childhood Endowment: Sixpence graphic
• Sixpence How It Works Fact Sheet
• Sixpence Annual Evaluation Report
Concurrent Session
Developing & Implementing a Common Intake & Referral System for Home Visiting
Presenters:
• Carlos Cano, U.S. Department of Health & Human Services Health Resources and
Services Administration (facilitator)
• Debbie Cheatham, Georgia Department of Public Health
• Wendy Grove, Ohio Department of Health
Session Key Points:
• Central intake systems can increase efficiencies and connect families to a broad array of
services that they need. They are effective ways of building linkages between home
visiting and other services such as early intervention.
• Central intake can systematize the process of matching families to appropriate services. It
can also be used to analyze records the state already has access to, such as birth
certificates, to identify families who may benefit from services.
• It is important to build in processes for alerting the system or people making referrals
when programs are at capacity so families are not sent to programs that cannot serve
them.
Full Session Notes:
Carlos Cano initiated the session by describing the benefits of a centralized intake system for
home visiting providers, including:
• creating efficiencies to connect families to services when multiple services are available;
• decreasing marketing and outreach costs that any one program has to assume;
• maximizing utilization of capacity for local programs;
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increasing the fit between the program and family needs; and
extending the choice of program and provider for families.
An advantage when thinking about implementing a centralized intake system as part of the
state’s home visiting infrastructure is that it can be developed gradually and scaled up over time.
Some states have chosen to pilot just within a certain community before broadening efforts
across the state.
Each of the state presenters then gave an overview of their central intake systems.
Georgia developed a Central Intake Call Center that they plan to launch in October 2012. Some
of the unique features of Georgia’s approach include:
• Development of a comprehensive data system for online referrals and its interface with
Georgia’s Vital Records system for receiving electronic birth certificates.
o Birth certificates are automatically screened, and families that could benefit from
home visiting are sent to the appropriate county for referral.
• Great Start Georgia framework and where the centralized intake process fits within the
overall framework. The framework has also helped partners understand the overall intent
of Great Start Georgia and where they fit within it.
Ohio’s central intake system was initiated over 10 years ago to increase access to the state’s early
intervention and statewide home visiting programs. It now also includes MIECHV funded
programs.
• Currently the system operates in all 88 counties with a 1-800 number
• Last year 41,000 referrals came through the centralized system (2/3 for early intervention
and 1/3 for home visiting), with about half of all referrals coming from physicians and
hospitals.
• Ohio will be moving to a regional (multi-county) system very soon. They are very
optimistic and enthused about the greater efficiencies this will afford them, by way of
more consistent data collection and an opportunity to provide more family choice.
• Ohio also hopes to expand the system to encompass all state early childhood initiatives
within the next 5 years, including the Race to the Top and Race to the Top Early
Learning Challenge grants.
The floor was then opened for questions.
• How did you select the system you chose to use?
o GA: Set it up as an open and competitive process, which allowed the state to learn
of other companies that could potentially do this work.
• What type of intake/input form is used?
o OH uses a common form for home visiting, which was combined with the state’s
Children’s First form as a single point of entry for EI and other public health
programs.
o In GA, the birth certificate will trigger referrals based on indicated EI criteria (if
identified at birth) and on risk factors related to maternal age and education level.
• How does the contractor update the resource directory? Is this done by the vendor or the
provider?
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o GA: Providers can have editing capability to make any modifications to program
descriptors.
How is family choice factored in?
o This is the advantage of a centralized intake system that is implemented by a
neutral vendor. The vendor is aware, through training, of resources in the
community and can provide this information to the family. By virtue of some
programs’ eligibility criteria, factors like gestational age may dictate whether
parent can be offered NFP, for example. So it is important that the system include
this type of decision tree. The system should be simplified to the greatest extent
possible and focused on using just a few questions, pertaining to place of
residence, whether there is developmental concern, age of child, and other needs
as families describe them , i.e. housing, parenting, etc.
What training is provided to centralized intake/care coordination contractors/vendors?
o There is a 2 day training that is required for central coordination contractors.
Training covers state rules, system goals, contract requirements, data system, and
understanding of the programs in the counties.
How is program capacity monitored?
o The state’s data system has been augmented and will provide, in real time, service
availability within each county. When the regional coordination contractor is
speaking with a family, s/he will be able to see what programs have openings and
which do not. Local service providers will be able to set and adjust their own
capacity limits, and the system will “gray” them out if at capacity to avoid
connecting families to services that are full.
Resources:
• Debbie Cheatham’s PowerPoint: Maternal Infant Early Childhood Home Visiting Central
Intake Call Center for Great Start Georgia
• Great Start Georgia: Georgia Early Childhood System of Care
• Great Start Georgia Fact Sheet
• Wendy Grove’s PowerPoint: Central Coordination
Concurrent Session
Linking Home Visiting with Child Care
Presenters:
• Steffanie Clothier, National Conference of State Legislatures (facilitator)
• Christine Johnson-Staub, Center for Law and Social Policy
• Nancy Keel, Kansas Parents as Teachers Association & Kansas Early Learning
Collaborative
Session Key Points:
• There is consensus that family, friend and neighbor child care providers are a logical and
important population to reach with home visiting services particularly because the data
show that large numbers of infants and toddlers spend significant amounts of time there.
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This is an emerging area of service development – there are no examples (that this group
could identify) of child care and home visiting service linkage at the state level. There are
some good examples at the local community level so the message to states is to
investigate those local examples and work on spreading them to other communities.
This is a win–win partnership. Child care quality can be improved through home visiting
services and the goals of home visiting can be better achieved by linking more children to
services through child care.
Full Session Notes:
Christine Johnson-Staub began the presentation by answering the question: Why would we be
interested in serving child care providers with home visiting services? She shared a new CLASP
resource: Home Away From Home: A Toolkit for Planning Home Visiting Partnerships with
Family, Friend and Neighbor Caregivers. CLASP found compelling statistics that large numbers
of children are in FFN care settings. They also considered the research on quality child care
environments; the large studies most of us are familiar with included a home visiting component.
Nancy Keel then described related work in Kansas. The Kansas work evolved through an early
learning cooperative group that included both home visiting model representatives and the state’s
resource and referral entity. The group agreed to work on some common issues together in a
broad way and began linking infrastructure supports such as training, screening, surveys, and
data systems. By focusing on this work together they noticed the significant disconnect between
home visiting and child care services at the community level.
Kansas started a small program with private dollars serving child care providers with the PAT
program: Supporting Care Providers Through Personal Visits.
• One of their main barriers is finding the funding to expand the service to more providers.
• An example of provider referral to the program occurs by asking families enrolled in
home visiting, “Who takes care of your children?” Then services are offered to that
provider via an introduction from the parents.
• Concurrently there is outreach done at the provider level - providers (and school district
staff and health providers) are invited to introductory group sessions that provide
program information.
• Implementation of the full curriculum with a provider takes approximately two years of
monthly visits, although there is some flexibility in the model to adjust visit frequency.
• The topic selected for each visit is decided by the provider educator partnering with the
provider to review their needs and interests and child needs.
• This particular curriculum focuses mainly on coaching providers on adult-child
interaction, child development and parent involvement
• Some benefits of the program, in addition to improving child care quality, are: ensuring
coordinated information to parents and providers; creating consistency for the child; and
protecting against duplication of activities such as screening that may be administered by
both a home visitor and child care provider.
The group was curious about how this model is different from on-site TA for child care. Nancy
explained that this model is similar but that it typically provides more basic information to
providers to better prepare them to receive quality improvement services. The school district
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program is also able to serve undocumented providers as documentation is not required for
school district services in Kansas. The SCPV Parents as Teachers Model is designed for any
person caring for children birth to age five.
Christine offered that this model developed by PAT is closer to on-site TA than some of the
other models described in CLASP’s Toolkit. She encouraged the group to consider three things
when deciding what kind of model to implement:
• The goals of the model
• The age of the children
• The specific components of the model
Every model included in the CLASP case studies includes the component of a home visitor
going into the home of the care provider. Some models also required providers to attend groups;
others also visited the home of the parent. Christine also noted that recruitment and identification
of interested providers was an important aspect to consider and that there are some unique
examples provided.
States can build support for this work by finding places where serving FFN providers with home
visiting services will help achieve the goals of existing initiatives:
• What are your stated goals of the MIECHV program, and who do you intend to serve?
• Where are you in the QRIS process, and does it include in-home providers?
• What are your school readiness goals?
The CLASP document provides information from all the MIECHV EBHV models – whether or
not there is a formal adaptation of the model that serves home-based providers, and if the model
has been used to serve this population.
Other ideas from the group on ways to connect home visiting and child care services:
• Resource and referral entities and the State Early Childhood Advisory Councils can be
good connectors for these services.
• Connect the services through the professional development system – core competencies
can cut across multiple systems.
• Lessons can be learned from IDEA Part C providers who serve child care providers.
• Look at the home visiting models you are implementing and find a topic that makes sense
to provide to the parent and child care provider together to initiate that linkage, such as
following up on a screening result.
Potential challenges:
• Developing a common language and working together across different goals.
• Finding the FFN providers at the state level – can start with subsidy records, but it is
extremely difficult to find providers for children who don’t receive a subsidy.
Resources:
• CLASP’s Home Away From Home: A Toolkit for Planning Home Visiting Partnerships
with Family, Friend, and Neighbor Caregivers
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