home visit quizlet

Reaching Families Where They Live: Supporting Parents and Child Development Through Home Visiting

• March 31, 2012

ZERO TO THREE strongly urges policymakers to continue supporting the expansion of evidence-based home visitation programs, so the diversity of families who need support can access it in a culturally appropriate manner.

Any new parent will likely tell you that parenting is the most rewarding, while also the most difficult, thing they have ever done. Especially during the first years of a child’s life, parents play the most active and influential role in their baby’s healthy growth and development. Parenting is difficult even in the best of circumstances, and when coupled with other stressful life events, it becomes even more challenging. During these times, support from others is critical. Unfortunately, many parents face obstacles—such as those caused by stress, language barriers, geographic and social isolation, poverty, and their own adverse childhood experiences that leave them without a positive parenting model—that impacts their ability to fully support their baby’s development during these critical years.

Home visiting has been demonstrated to be an effective method of supporting families, particularly as part of a comprehensive and coordinated system of high-quality, affordable early care and education, health and mental health, and family support services for families of children from the prenatal through the pre-kindergarten stages. These voluntary programs tailor services to meet the needs of individual families and offer information, guidance, and support directly in the home environment. While home visiting programs vary in goals and content of services, in general, they combine parenting and health care education, child abuse prevention, and early intervention and education services for young children and their families.

48 states, the District of Columbia, and 5 U.S. territories are currently operating home visiting programs through interagency planning efforts.

ZERO TO THREE strongly urges policymakers to continue supporting the expansion of evidence-based home visitation programs, so the diversity of families who need support can access it in a culturally appropriate manner. ZERO TO THREE also encourages the development of infrastructure to sustain the growing network of programs across the country. The infrastructure would ensure that programs are high quality, true to their intended model, and linked to other critical early childhood systems, thereby creating a seamless and holistic network of support for at risk families.

New Federal Support for Home Visitation

Home visiting received an unprecedented boost in 2010 through the passage of the Patient Protection and Affordable Care Act, which established the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. This program provides $1.5 billion over 5 years to states to establish evidence-based home visiting programs for at-risk pregnant and parenting women, children from birth to age 5, and their families. The majority of the funding is used by states to implement program models that have demonstrated their effectiveness based on rigorous evaluation findings. The remaining portion of funds is distributed through states to “promising approaches” that have not yet demonstrated their efficacy with evidence that meets the level of rigor required by federal mandates, but must be evaluated if implemented through MIECHV. These significant new resources have led to the addition and expansion of home visiting programs in communities across the country. In addition, resources are being allocated to expand new infrastructure-building initiatives to bolster the field of home visiting and better integrate home visiting services into a broad system of early childhood supports. The evaluation component of the MIECHV initiative, which includes all competitive and promising approach awards, will also contribute new understanding of home visiting implementation among the diverse populations it aims to support.

Home Visiting Infographic

A trusted face at the front door can bring parents the support they need to nurture their young child’s healthy development. Home visiting reaches families where they live by delivering parent support and child development services directly in the home environment.

Policy Recommendations

1. support the development and expansion of evidence-based home visiting models endorsed by miechv and other promising high-quality programs with a proven track record of success..

In planning for MIECHV, Mathematica Policy Research, Inc., in partnership with key federal agencies under the Administration for Children and Families (ACF), launched Home Visiting Evidence of Effectiveness (HomVEE) to conduct a transparent and extensive review of home visiting research and assess the quality and rigor of the evidence. This assessment determined which home visiting models are considered evidence-based and thus could be selected and implemented by the states with federal MIECHV dollars. HomVEE has also established an ongoing process to review new research literature that may be in the evaluation pipeline. See  http://homvee.acf.hhs.gov/  for more information. While the growth of the approved program models will lead to more parents receiving this critical support during their child’s early years, many families will still not have access to high-quality research-based programs. Current MIECHV implementation data shows that new funding reaches 15% of U.S. counties. Policymakers should continue to expand access and funding for parent support and child development services delivered through home visiting, paying attention to resources that not only support the delivery of home visiting services but also support the rigorous evaluation of current evidence-based models and promising approaches in operation across the country.

2. Develop a continuum of care for young children and their families by coordinating home visiting efforts with other child development and family services in the community.

Connecting home visiting efforts, particularly those focused on children’s well-being and healthy development, with other child and family services in communities will help to ensure that young children and parents have the comprehensive support they need. In instances when parents and children have needs beyond those addressed by the home visiting program in which they are enrolled, they should be linked to additional resources available in their community, such as high-quality child care programs and comprehensive early childhood programs such as Early Head Start, early intervention programs, health assistance programs, and mental health services.

Every state has created a comprehensive child find and referral system under Part C of the Individuals With Disabilities Education Act, and there are explicit requirements for states to coordinate early identification efforts between health, social service, and educational systems. Similar coordination efforts are required under the Health Resources and Services Administration (HRSA) Maternal and Child Health Early Childhood Comprehensive Systems (ECCS) grant program. ECCS grants help states and communities to build and integrate early childhood service systems in the areas of a) access to health care and medical homes, b) social-emotional development and mental health, c) early care and education, d) parenting education, and e) family support. State efforts to expand home visiting should formally integrate these services and ensure that families are being appropriately matched with available home visiting and other early childhood services.

However, in many communities, high-quality clinical intervention services (i.e., substance abuse treatment and mental health) are neither available nor accessible to parents with very young children. State leadership that encourages the development of the continuum of care is critical to the success of home visiting. This leadership can take the form of gubernatorial initiatives, interagency planning groups, or system changes to provide universal access to services.

3. Build state systems for home visitation and integrate home visiting infrastructure into broader early childhood systems.

As states and communities establish and expand home visiting services, the need for state-level infrastructure to support program development becomes essential. Such system work includes developing state-supported and coordinated efforts in the areas of professional development, cross-model standards, data collection and evaluation, continuous quality improvement, and processes to deliver high-quality technical assistance. Home visiting initiatives at the state level should seek to coordinate across all home visiting programs being implemented within the state (whether federally funded or not), while also embedding home visiting within a broader state early childhood system. Federal regulations for related programs create opportunities for collaborative state and community planning. For example, home visits are included with family training and counseling as part of the definition of early intervention services under Part C and, according to the most recent data reports, approximately 87% of all Part C services for infants and toddlers with developmental delays or disabilities are provided in home settings.

Representatives of home visiting programs should participate in community and statewide collaborative groups to improve the coordination of services for young children and their families across agencies and programs. In addition, governors should appoint home visiting representatives to the State Advisory Councils on Early Childhood Education and Care and other state-specific early childhood oversight boards. MIECHV has supported the development of home visiting systems through the availability of competitive grants that reward program expansion and encourage the development of system infrastructure components.

4. Ensure that home visiting services are culturally competent, responsive, and language appropriate.

Home visiting programs serve an ethnically diverse population including immigrant and refugee families. In this country, 63% of infants and toddlers (under age 3) with immigrant parents—1.3 million—live in low-income families. In addition, Black, American Indian, and Hispanic children represent a disproportionate share of the low-income population under age 3 (55%). Home visiting services have been found to reduce the language and cultural barriers faced by families and ensure that parents receive the support and resources they need to promote their child’s healthy development, despite the obstacles presented by poverty. Policymakers and program administrators should ensure that services delivered through home visiting programs are culturally appropriate and consider the barriers that families endure in today’s society and economy. In order to engage, retain, and support diverse populations, home visiting programs must integrate cultural competency and responsiveness into every aspect of the design and implementation of the program.

5. Ensure that all home visiting initiatives incorporate known elements of effectiveness and best practices.

There is growing consensus on the list of key elements of effective home visiting models that are most likely to achieve outcomes for young children and their families. This list includes: solid internal consistency that links specific program elements to specific outcomes, well-trained and competent staff, high-quality reflective supervision that includes observation of the provider and participant, strong leadership and organizational capacity, linkages to other community resources and supports, and consistent implementation of program components. Policymakers should ensure that new home visiting initiatives utilize models that incorporate these key elements and are focused on high-quality service design and delivery. In addition, as services are expanded within states, policymakers should ensure that program models are implemented with commitment to fidelity so that key elements are not diluted as the programs expand.

6. Support rigorous, ongoing evaluation and continuous quality improvement efforts for home visiting programs.

Program evaluation allows home visitors, supervisors, funders, families, and policymakers to know whether a program is being implemented as designed and how closely it is meeting its objectives. This information can be used to continually refine and improve service delivery for young children and their families, as well as provide an evidence-based rationale for the expansion of home visiting programs. When financing home visiting programs, policymakers should ensure that adequate time and funding are included for thorough evaluation.

7. Ensure that home visiting services address the distinct needs of high-risk families, including those coping with the challenges of domestic violence, substance abuse, and mental health issues.

Home visiting programs report that families are experiencing higher risk issues over time, with many participants experiencing multiple risk factors simultaneously. Domestic violence, maternal depression, and addiction plague many home visiting participants, which often makes effective intervention with those families challenging for home visiting professionals. Home visiting and other early childhood programs are evolving to meet these high-risk needs, and effective models are emerging to assist these populations. Services to high-risk families can either be integrated into the home visiting programs themselves or connected via community linkages and referral systems. Policymakers and administrators should direct attention to these emerging models and continue to build support for this difficult work.

Home Visiting Evaluation and MIECHV

MIECHV has launched an array of efforts to strengthen and facilitate states’ efforts in tracking benchmark data, strengthening evaluation efforts, developing data systems, and implementing quality assurance systems. The body of evaluation findings that will emerge through MIECHV at both the state and national levels will be a tremendous asset to the further evolution of the home visiting field. As of the publication of this issue brief, 12 programs have been deemed “evidence-based” by the MIECHV initiative through the HomVEE assessment. Those models include: Child FIRST, Early Head Start-Home Visiting, Early Intervention Program for Adolescent Mothers (EIP), Early Start (New Zealand), Family Check-Up, Healthy Families America (HFA), Healthy Steps, Home Instruction for Parents of Preschool Youngsters (HIPPY), Nurse Family Partnership (NFP), Oklahoma’s Community-Based Family Resource and Support (CBFRS) Program, Parents as Teachers (PAT), Play and Learning Strategies (PALS) Infant6, and SafeCare Augmented. For more information on model specifics, see:  http://homvee.acf.hhs.gov/Default.aspx . The federal home visiting evaluation efforts include:

Mother and Infant Home Visiting Program Evaluation (MIHOPE)

MIHOPE is sponsored by the U.S. Department of Health and Human Services, ACF, and HRSA. This evaluation, mandated by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), is designed to build knowledge for policymakers and practitioners about the effectiveness of the MIECHV program in improving outcomes for at-risk children and families. The study includes: an analysis of the state needs assessments that were provided in the state MIECHV applications and an effectiveness study that includes an impact analysis to measure what difference home visiting programs make for the at-risk families they serve in areas such as prenatal, maternal, and newborn health; child development; parenting; domestic violence; and referrals and service coordination. The effectiveness study will also include an implementation analysis that will examine how the program models operate in their local and state contexts and describe the families who participate; and an economic analysis that will examine the financial costs of operating the programs.

A special goal of this study is the linking of implementation strategies to program impacts, thus informing the field about the types of program features or strategies that might lead to even greater impacts on families. For example, understanding how, and at what level, the average family participates in the program will provide context to any variation in impacts we find in the health of families. The primary data used in the study are expected to be collected by the research team through surveys, review of administrative records, interviews, observations, and staff logs. The study will be conducted by a team of organizations: MDRC (the lead), James Bell Associates, Johns Hopkins University, Mathematica Policy Research, and the University of Georgia.

Design Options for Home Visiting Evaluation (DOHVE)

The DOHVE project provides research- and evaluation-related technical assistance (TA) to MIECHV program grantees. Specifically, the DOHVE TA team assists state, territory, and tribal grantees with:

• developing plans for collecting data on benchmarks;
• designing and strengthening evaluations of promising programs and evaluations being done as part of competitive grant projects;
• selecting, adapting, and developing data collection tools and measures;
• developing and adapting data systems to facilitate tracking and reporting on federal benchmarks;
• designing and implementing continuous quality improvement (CQI) systems; and,
• establishing data protection and privacy policies and procedures.

This TA is provided through webinars, facilitated group calls with multiple grantees, technical assistance resource documents, and individual grantee calls, meetings, and written feedback.

The DOHVE project is funded by ACF and HRSA, and the work is performed under a contract awarded to MDRC, James Bell Associates, and Cincinnati Children’s Hospital Medical Center. For more information about DOHVE and links to the TA resources it has created, please see  www.mdrc.org/dohve/dohve_resources.html .

Tribal Home Visiting Evaluation Institute (TEI)

The ACF Office of Planning, Research and Evaluation (OPRE) awarded the TEI contract to provide technical assistance, leadership, and support to promote excellence in community-based research and evaluation of MIECHV initiatives that serve American Indian and Alaska Native (AIAN) children and families through the Tribal Maternal, Infant, and Early Childhood Home Visiting program. The TEI will engage in activities that support tribal home visiting grantees in the identification and development of effective practices and systems for integrated services for home visiting in tribal communities. Examples of focal areas include: developing and implementing a rigorous evaluation of home visiting; selecting, adapting, and developing culturally appropriate data collection tools and measures; tracking and measuring benchmarks; developing and modifying existing data systems; continuous quality improvement; data protection and privacy; and ethical dissemination and translation of evaluation findings derived from research with AIAN to external audiences.

The staffing of the TEI reflects an understanding and sensitivity to issues of conducting an evaluation in a tribal setting and includes researchers who have a history of working with AIAN communities on the evaluation of home visiting. In FY11 the contractor has been funded to provide individualized, grantee-specific guidance around research and evaluation topics; begin analyzing and synthesizing challenges faced by grantees around research and evaluation; develop comprehensive, user-friendly synthesis of guidance for tribal grantees; and work with grantees on efforts to disseminate and share the knowledge they are building regarding effective home visiting in tribal communities. These activities will continue for the full 4-year contract. The award was made to MDRC, James Bell Associates, Johns Hopkins University, and University of Colorado at Denver.

A growing body of research demonstrates that home visiting can be an effective method of delivering family support and child development services. While home visiting programs share similar overall goals of enhancing child well-being and family health, they vary in their program structure, specific intended outcomes, content of services, and targeted populations. Over time, however, certain key cross-model outcome areas have emerged, including positive impacts on:

• school readiness,
• child health and development,
• child abuse and neglect,
• parenting practices,
• family economic self-sufficiency, and
• maternal health.

The following presents a sampling of research from the home visitation field. Full literature reviews and study details are available at  http://homvee.acf.hhs.gov/Default.aspx .

High-quality home visiting programs can increase children’s readiness for school.

The first 3 years of life are a period of intense intellectual development during which the brain forms a foundation for later learning and development. High-quality home visiting programs can be an effective service delivery method to support early learning in these years, ensuring that children succeed in school and beyond. When compared to control group counterparts in randomized trials, infants and toddlers who participated in high-quality home visiting programs were shown to have more favorable scores for cognitive development and behavior, higher IQs and language scores, higher grade point averages and math and reading achievement test scores at age 9, and higher graduation rates from high school. One 7-year followup study showed that children enrolled in a high-quality home visiting program were more likely to participate in a gifted program and less likely to receive special education services or report skipping school than were children in the control group. In addition, two studies using stratified random sampling found that a high-quality home visiting program positively impacted school readiness through better parenting practices, increased reading to children at home, and a greater likelihood of enrollment in preschool programs.

High-quality home visiting programs can improve child health and development.

The domains of development are inextricably linked during the early years of life, and children need support for their physical, cognitive, and social-emotional development to thrive. Randomized trial research demonstrates that high-quality home visiting programs can be effective supports for children’s healthy development. Compared to control groups, babies of parents enrolled prenatally in home visiting programs had better birth outcomes, and the programs were found to have a positive impact on breastfeeding and immunization rates., In other randomized trials, participating children were found to have a reduction in language delays at 21 months, reductions in mental health problems, fewer behavior problems, and increased mental development. In addition, when compared to control groups, children of teen mothers who participated in a home visiting program showed gains in cognitive development.

High-quality home visiting programs can reduce child abuse and neglect.

Infants and toddlers need safe and nurturing surroundings in which they can develop and grow. By working with parents in their own environments, home visiting programs can reduce child abuse and neglect. In a randomized trial, a home visiting program reduced physical and psychological abuse after 1 year of participation and had the greatest impact on first-time and psychologically vulnerable mothers after 2 years of participation. In addition, compared to control groups, teen mothers who participated in a home visiting program and received comprehensive case management had fewer opened cases of child abuse or neglect. Finally, another randomized control trial at 7 years followup showed an 80% reduction in the average number of acts of serious physical abuse.

High-quality home visiting programs can enhance parents’ abilities to support their children’s overall development.

To ensure that babies grow up healthy and ready to learn, parents need resources and tools to help them fully support their child’s development. In randomized trials, home visiting programs were found to be effective methods for delivering these essential parent support services. When compared to control group counterparts, parents with very low incomes who participated in a home visiting program were more likely to read aloud, tell stories, say nursery rhymes, and sing with their child. Participants in home visiting programs also created more developmentally stimulating home environments, had more responsive interactions with their children, and knew more about child development. One high-quality program found that mothers were more likely to use appropriate limit-setting and parenting strategies that stimulated the child’s cognitive skills and to report using nonviolent discipline strategies.

High-quality home visiting programs can improve family economic self-sufficiency.

Economic security is vital for families with young children, yet a large percentage of families across our country continually struggle with attaining financial self-sufficiency and stability. Close to 15 million children in the United States (21% of all children) live in families with incomes below the federal poverty level. Poverty negatively impacts children’s physical, social, and emotional development and can impede their ability to learn. The risks are exacerbated for children who experience poverty when they are very young. Home visitation programs can counteract the negative consequences of economic insecurity and encourage success not only at home but also in school and at work. Home visitation programs help parents enroll in educational and training programs and pursue employment opportunities. In a series of randomized controlled trials of a nurse home visitation program serving unmarried low-income women, 82% more participants worked compared to the control group in the period up until their child turned 4. In another trial of the same program, participants were twice as likely to be employed as the control group at their child’s second birthday. A randomized controlled trial of another program demonstrated high participation in school or training compared to the rate of the control group; a particular benefit of this program was the setting of concrete goals with the mothers for their education and professional development. Finally, a 5-year followup study of another home visitation program found higher monthly income for study participants.

High-quality home visiting programs can improve maternal health.

The physical and mental transformations a woman goes through during pregnancy and after are significant and life changing. Home visitation programs often connect pregnant women to prenatal services to ensure a safe labor and delivery outcome for both the newborn and the mother. Home visitation programs also support the mother’s ongoing physical and mental health during the post-partum period as she navigates the changes that come her way. A series of randomized control trials of a nurse home visitation program show a range of positive effects on maternal health, including decreases in prenatal cigarette smoking, fewer hypertensive disorders in pregnancy, and fewer closely spaced subsequent pregnancies., A randomized control study of another program that works with a particularly high-risk population found that participant mothers showed significantly lower depressive symptoms than those in the control group and were less likely to report feeling stressed a year after participation. Finally, a randomized control study showed significantly less use of alcohol at 6-month and 1-year followups of a home visiting program.

Early childhood home visitation has a promising future that builds on its successful history serving vulnerable families across our nation. The new federal investments in home visiting augment a variety of existing state and private funding sources and provide an unprecedented opportunity to advance the field and positively impact a diverse array of the children and families most in need.

For citations, download the full  PDF.

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KEY COMPONENTS IN HOME VISITS

1. Assessment:

• Conduct a thorough assessment of the home environment, including living conditions, safety hazards, and available support systems.

2. Purpose of the Visit:

• Clearly define the purpose of the home visit, whether it is for routine check-ups, health education, medication management, post-discharge follow-up, or addressing specific health concerns.

3. Appointment and Consent:

• Schedule home visits at convenient times for the client and obtain consent for the visit. Respect the client’s privacy and autonomy.

4. Communication:

• Establish effective communication with the client and their family. Listen actively, address concerns, and encourage open dialogue to better understand their needs.

5. Cultural Competence:

• Be culturally competent and respectful of the client’s cultural practices, beliefs, and values. Consider cultural factors when planning and delivering care.

6. Safety Precautions:

• Assess and address safety concerns in the home, including fall risks, fire hazards, and other environmental factors. Provide education on maintaining a safe living space.

7. Medication Management:

• Review medications with the client, ensuring proper administration and understanding. Address any concerns or questions regarding medications.

8. Health Education:

• Provide individualized health education on topics such as chronic disease management, nutrition, hygiene, and preventive care. Use visual aids and written materials as needed.

9. Family Involvement:

• Involve family members or caregivers in the care plan, as appropriate. Consider their support and collaboration in maintaining the client’s health.

10. Health Promotion: – Encourage and facilitate healthy lifestyle choices. Discuss strategies for maintaining or improving health and preventing illness.

11. Assessment of Activities of Daily Living (ADLs): – Evaluate the client’s ability to perform daily activities, such as bathing, dressing, and eating. Provide assistance or make recommendations for improvement as needed.

12. Monitoring and Follow-up: – Establish a plan for ongoing monitoring and follow-up. Determine the frequency of home visits based on the client’s needs and the nature of the healthcare issue.

13. Documentation: – Document the home visit thoroughly, including assessments, interventions, education provided, and any changes in the client’s health status. Maintain accurate and up-to-date records.

14. Collaboration with Other Healthcare Providers: – Collaborate with other healthcare professionals involved in the client’s care, such as physicians, therapists, and social workers. Ensure a coordinated and holistic approach.

15. Respect for Autonomy: – Respect the client’s autonomy and involve them in decision-making regarding their care. Encourage them to express their preferences and goals for health and well-being.

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Home Visit: Opening the Doors for Family Health

Chapter 11 Home Visit Opening the Doors for Family Health Claudia M. Smith Chapter Outline Home Visit Definition Purpose Advantages and Disadvantages Nurse–Family Relationships Principles of Nurse–Client Relationship with Family Phases of Relationships Characteristics of Relationships with Families Increasing Nurse–Family Relatedness Fostering a Caring Presence Creating Agreements for Relatedness Increasing Understanding through Communication Skills Reducing Potential Conflicts Matching the Nurse’s Expectations with Reality Clarifying Nursing Responsibilities Managing the Nurse’s Emotions Maintaining Flexibility in Response to Client Reactions Clarifying Confidentiality of Data Promoting Nurse Safety Clarifying the Nurse’s Self-Responsibility Promoting Safe Travel Handling Threats during Home Visits Protecting the Safety of Family Members Managing Time and Equipment Structuring Time Handling Emergencies Promoting Asepsis in the Home Modifying Equipment and Procedures in the Home Postvisit Activities Evaluating and Planning the Next Home Visit Consulting and Collaborating with the Team Making Referrals Legal Documentation The Future of Evidence-Based Home-Visiting Programs Focus Questions Why are home visits conducted? What are the advantages and disadvantages of home visits? How is the nurse–client relationship in a home similar to and different from nurse–client relationships in inpatient settings? How can a nurse’s family focus be maximized during a typical home visit? What promotes safety for community/public health nurses? What happens during a typical home visit? How can client participation be promoted? Key Terms Agreement Collaboration Consultation Empathy Family focus Genuineness Home visit Positive regard Presence Referral Nurses who work in all specialties and with all age groups can practice with a family focus , that is, thinking of the health of each family member and of the entire family per se and considering the effects of the interrelatedness of the family members on health. Because being family focused is a philosophy, it can be practiced in any setting. However, a family’s residence provides a special place for family-focused care. Community/public health nurses have historically sought to promote the well-being of families in the home setting ( Zerwekh, 1990 ). Community/public health nurses seek to promote health; prevent specific illnesses, injuries, and premature death; and reduce human suffering. Through home visits, community/ public health nurses provide opportunities for families to become aware of potential health problems, to receive anticipatory education, and to learn to mobilize resources for health promotion and primary prevention ( Kristjanson & Chalmers, 1991 ; Raatikainen, 1991 ). In clients’ homes, care can be personalized to a family’s coping strategies, problem-solving skills, and environmental resources (see Chapter 13 ). During home visits, community/public health nurses can uncover threats to health that are not evident when family members visit a physician’s office, health clinic, or emergency department ( Olds et al., 1995 ; Zerwekh, 1991 ). For example, during a visit in the home of a young mother, a nursing student observed a toddler playing with a paper cup full of tacks and putting them in his mouth. The student used the opportunity to discuss safety with the mother and persuaded her to keep the tacks on a high shelf. The quality of the home environment predicts the cognitive and social development of an infant ( Engelke & Engelke, 1992 ). Community/public health nurses successfully assist parents in improving relations with their children and in providing safe, stimulating physical environments. All levels of prevention can be addressed during home visits. Research has demonstrated that home visits by nurses during the prenatal and infancy periods prevent developmental and health problems ( Kitzman et al., 2000 ; Norr et al., 2003 ; Olds et al., 1986 ). Olds and colleagues demonstrated that families who received visits had fewer instances of child abuse and neglect, emergency department visits, accidents, and poisonings during the child’s first 2 years of life. These results were true for families of all socioeconomic levels but greater for low-income families. The health outcomes for families who received home visits were better than those of families that received care only in clinics or from private physicians. Furthermore, the favorable results were still apparent 15 years after the birth of the first child ( Olds et al., 1997 ), and the home visits reduced subsequent pregnancies ( Kitzman et al., 1997 ; Olds et al., 1997 ). The U.S. Advisory Board on Abuse and Neglect advocates such home-visiting programs as a means to prevent child abuse and neglect ( U.S. Department of Health and Human Services, 1990 ). Other research shows that home visits by nurses can reduce the incidence of drug-resistant tuberculosis and decrease preventable deaths among infected individuals ( Lewis & Chaisson, 1993 ). This goal is achieved through directly observing medication therapy in the individual’s home, workplace, or school on a daily basis or several times a week (see Chapter 8 ). Several factors have converged to expand opportunities for nursing care to adults and children with illnesses and disabilities in their homes. The American population has aged, chronic diseases are now the major illnesses among older persons, and attempts are being made to limit the rising hospital costs. As the average length of stay in hospitals has decreased since the early 1980s, families have had to care for more adults and children with acute illnesses in their homes. This increased demand for home health care has resulted in more agencies and nurses providing home care to the ill and teaching family members to perform the care (see Chapter 31 ). The degree to which families cope with a member with a chronic illness or disability significantly affects both the individual’s health status and the quality of life for the entire family ( Burns & Gianutsos, 1987 ; Harris, 1995 ; Whyte, 1992 ). Family members may be called on to support an individual family member’s adjustment to a chronic illness as well as take on tasks and roles that the ill member previously performed. This adjustment occurs over time and often takes place in the home. Community/public health nurses can assist families in making these adjustments. Since the late 1960s, deinstitutionalization of mentally ill clients has shifted them from inpatient psychiatric settings to their own homes, group homes, correctional facilities, and the streets (see Chapter 33 ). Nurses in the fields of community mental health and psychiatry began to include the relatives and surrogate family members in providing critical support to enable the person with a psychiatric diagnosis to live at home ( Mohit, 1996 ; Stolee et al., 1996 ). The hospice movement also recognizes the importance of a family focus during the process of a family member’s dying ( American Nurses Association [ANA], 2007a ). Care at home or in a homelike setting is cost effective under many circumstances. As the prevalence of acquired immunodeficiency syndrome (AIDS) increases and the number of older adults continues to increase, providing care in a cost-effective manner is both an ethical and an economic necessity. Nurses in any specialty can practice with a family focus. However, the specific goals and time constraints in each health care service setting affect the degree to which a family focus can be used. A home visit is one type of nurse–client encounter that facilitates a family focus. Home visiting does not guarantee a family focus. Rather, the setting itself and the structure of the encounter provide an opportunity for the nurse to practice with a family focus. A nurse visiting a client in his home listens to the man’s heart while his daughter looks on. Nurses who graduate from a baccalaureate nursing program are expected to have educational experiences that prepare them for beginning practice in community/public health nursing. Family-focused care is an essential element of community/public health nursing. One of the ways to improve the health of populations and communities is to improve the health of families ( ANA, 2007b ). Home visits may be made to any residence: apartments for older adults, group homes, boarding homes, dormitories, domiciliary care facilities, and shelters for the homeless, among others. In these residences, the family may not be related by blood, but, rather, they may be significant others: neighbors, friends, acquaintances, or paid caregivers. Nurses who are educated at the baccalaureate level are one of a few professional and service workers who are formally taught about making home visits. Some social work students, especially those interested in the fields of home health and protective services, also receive similar education. The American Red Cross and the National Home Caring Council have developed training programs for homemakers and home health aides; not all aides have received such extensive training, however. Agricultural and home economic extension workers in the United States and abroad also may make home visits ( Murray, 1968 ; World Health Organization, 1987 ). Home visit Definition A home visit is a purposeful interaction in a home (or residence) directed at promoting and maintaining the health of individuals and the family (or significant others). The service may include supporting a family during a member’s death. Just as a client’s visit to a clinic or outpatient service can be viewed as an encounter between health care professionals and the client, so can a home visit. A major distinction of a home visit is that the health care professional goes to the client rather than the client coming to the health care professional. Purpose Almost any health care service can be accomplished on a home visit. An assumption is that—except in an emergency—the client or family is sufficiently healthy to remain in the community and to manage health care after the nurse leaves the home. The foci of community/public health nursing practice in the home can be categorized under five basic goals: 1.  Promoting support systems that are adequate and effective and encouraging use of health-related resources 2.  Promoting adequate, effective care of a family member who has a specific problem related to illness or disability 3.  Encouraging normal growth and development of family members and the family and educating the family about health promotion and illness prevention 4.  Strengthening family functioning and relatedness 5.  Promoting a healthful environment The five basic goals of community/public health nursing practice with families can be linked to categories of family problems ( Table 11-1 ). A pilot study to identify problems common in community/public health nursing practice settings revealed that problems clustered into four categories: (1) lifestyle and living resources, (2) current health status and deviations, (3) patterns and knowledge of health maintenance, and (4) family dynamics and structure ( Simmons, 1980 ). Home visits are one means by which community/public health nurses can address these problems and achieve goals for family health. Table 11-1 Family Health-Related Problems and Goals Problem * Goal Lifestyle and resources Promote support systems and use of health-related resources Health status deviations Promote adequate, effective family care of a member with an illness or disability Patterns and knowledge of health maintenance Encourage growth and development of family members, health promotion, and illness prevention Promote a healthful environment Family dynamics and structure Strengthen family functioning and relatedness * Problems from Simmons, D. (1980). A classification scheme for client problems in community health nursing (DHHS Pub No. HRA 8016). Hyattsville, MD: U.S. Department of Health and Human Services. Advantages and Disadvantages Advantages of home visits by nurses are numerous. Most of the disadvantages relate to expense and concerns about unpredictable environments ( Box 11-1 ). Box 11-1 Advantages and Disadvantages of Home Visiting Advantages •  Home setting provides more opportunities for individualized care. •  Most people prefer to receive care at home. •  Environmental factors impinging on health, such as housing condition and finances, may be observed and considered more readily. •  Collecting information and understanding lifestyle values are easier in family’s own environment. •  Participation of family members is facilitated. •  Individuals and family members may be more receptive to learning because they are less anxious in their own environments and because the immediacy of needing to know a particular fact or skill becomes more apparent. •  Care to ill family members in the home can reduce overall costs by preventing hospitalizations and shortening the length of time spent in hospitals or other institutions. •  A family focus is facilitated. Disadvantages •  Travel time is costly. •  Home visiting is less efficient for the nurse than working with groups or seeing many clients in an ambulatory site. •  Distractions such as television and noisy children may be more difficult to control. •  Clients may be resistant or fearful of the intimacy of home visits. •  Nurse safety can be an issue. Nurse–family relationships How nurses are assigned to make home visits is both a philosophical and a management issue. Some community/public health nurses are assigned by geographical area or district . The size of the geographical area for home visits varies with the population density. In a densely populated urban area, a nurse might visit in one neighborhood; in a less densely populated area, the nurse might be assigned to visit in an entire county. With geographical assignments, the nurse has the potential to work with the entire population in a district and to handle a broad range of health concerns; the nurse can also become well acquainted with the community’s health and social resources. The potential for a family-focused approach is strengthened because the nurse’s concerns consist of all health issues identified with a specific family or group of families. The nurse remains a clinical generalist, working with people of all ages. Other community/public health nurses are assigned to work with a population aggregate in one or more geopolitical communities. For example, a nurse may work for a categorical program that addresses family planning or adolescent pregnancy, in which case the nurse would visit only families to which the category applies. This type of assignment allows a nurse to work predominantly with a specific interest area (e.g., family planning and pregnancy) or with a specific aggregate (e.g., families with fertile women). Principles of Nurse–Client Relationship with Family Regardless of whether the community/public health nurse is assigned to work with an aggregate or the entire population, several principles strengthen the clarity of purpose: •  By definition, the nurse focuses on the family. •  The health focus can be on the entire spectrum of health needs and all three levels of prevention. •  The family retains autonomy in health-related decisions. •  The nurse is a guest in the family’s home. Family Focus To relate to the family, the community/public health nurse does not have to meet all members of the household personally, although varying the times of visits might allow the nurse to meet family members usually at work or school. Relating to the family requires that the nurse be concerned about the health of each member and about each person’s contribution to the functioning of the family. One family member may be the primary informant; in such instances, the nurse should realize that the information received is being filtered by the person’s perceptions. The community/public health nurse should take the time to introduce herself or himself to each person present and address each person by name. Building trust is an essential foundation for a continued relationship ( Heaman et al., 2007 ; McNaughton, 2000 ; Zerwekh, 1992 ). The nurse should use the clients’ surnames unless they introduce themselves in another way or give permission for the nurse to be less formal. Interacting with as many family members as possible, identifying the family member most responsible for health issues, and acknowledging the family member with the most authority are important. The nurse should ask for an introduction to pets and ask for permission before picking up infants and children unless it is granted nonverbally. A nurse enters the home of a client with a young child. All Levels of Prevention Through assessment, the community/public health nurse attempts to identify what actual and potential problems or concerns exist with each individual and, thematically, within the family (see Chapter 13 ). Issues of health promotion (diet) and specific protection (immunization) may exist, as may undiagnosed medical problems for which referral is necessary for further diagnosis and treatment. Home visits also can be effective in stimulating family members to seek appropriate services such as prenatal care ( Bradley & Martin, 1994 ) and immunizations ( Norr et al., 2003 ). Actual family problems in coping with illness or disability may require direct intervention. Preventing sequelae and maximizing potential may be appropriate for families with a chronically ill member. Health-related problems may appear predominantly in one family member or among several members. A thematic family problem might be related to nutrition. For example, a mother may be anemic, a preschooler may be obese, and a father may not follow a low-fat diet for hypertension. Family Autonomy A few circumstances exist in our society in which the health of the community, or public, is considered to have priority over the right of individual persons or families to do as they wish. In most states, statutes (laws) provide that health care workers, including community/public health nurses, have a right and an obligation to intervene in cases of family abuse and neglect, potential suicide or homicide, and existence of communicable diseases that pose a threat of infection to others. Except for these three basic categories, the family retains the ultimate authority for health-related decisions and actions . In the home setting, family members participate more in their own care. Nursing care in the home is intermittent, not 24 hours a day. When the visit ends, the family takes responsibility for their own health, albeit with varying degrees of interest, commitment, knowledge, and skill. This role is often difficult for beginning community/public health nurses to accept; learning to distinguish the family’s responsibilities from the nurse’s responsibilities involves experience and consideration of laws and ethics. Except in crises, taking over for the family in areas in which they have demonstrated capability is usually inappropriate. For example, if family members typically call the pharmacy to renew medications and make their own medical appointments, beginning to do these things for them is inappropriate for the nurse. Taking over undermines self-esteem, confidence, and success. Nurse as Guest Being a guest as a community/public health nurse in a family’s home does not mean that the relationship is social. The social graces for the community and culture of the family must be considered so that the family is at ease and is not offended. However, the relationship is intended to be therapeutic. For example, many older persons believe that offering something to eat or drink is important as a sign that they are being courteous and hospitable. Because your refusal to share in a glass of iced tea may be taken as an affront, you may opt to accept the tea. However, you certainly have the right to refuse, especially if infectious disease is a concern. Validate with the client that the time of the visit is convenient. If the client fails to offer you a seat, you may ask if there is a place for you and the family to sit and talk. This place may be any room of the house or even outside in good weather. Phases of Relationships Relatedness and communication between the nurse and the client are fundamental to all nursing care. A nurse–client relationship with a family (rather than an individual) is critical to community/public health nursing. The phases of the nurse–client relationship with a family are the same as are those with an individual. Different schemes have been developed for naming phases of relationships. All schemes have (1) a preinitiation or preplanning phase, (2) an initiation or introductory phase, (3) a working phase, and (4) an ending phase (Arnold & Boggs, 2011). Some schemes distinguish a power and control or contractual phase that occurs before the working phase. The initiation phase may take several visits. During this phase, the nurse and the family get to know one another and determine how the family health problems are mutually defined. The more experience the nurse has, the more efficient she or he will become; initially, many community/public health nursing students may require four to six visits to feel comfortable and to clarify their role ( Barton & Brown, 1995 ). The nursing student should keep in mind that the relationship with the family usually involves many encounters over time—home visits, telephone calls, or visits at other ambulatory sites such as clinics. Several encounters may occur during each phase of the relationship ( Figure 11-1 ). Each encounter also has its own phases ( Figure 11-2 ). Figure 11-1 A series of encounters during a relationship. (Redrawn from Smith, C. [1980]. A series of encounters during a relationship [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Figure 11-2 Phases of a home visit. (Redrawn from Smith, C. [1980]. Phases of a home visit [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Preplanning each telephone call and home visit is helpful. Box 11-2 lists activities in which community/public health nurses usually engage before a home visit. The list can be used as a guide in helping novice community/public health nurses organize previsit activities efficiently. Box 11-2 Planning Before a Home Visit   1.  Have name, address, and telephone number of the family, with directions and a map. 2.  Have telephone number of agency by which supervisor or faculty can be reached. 3.  Have emergency telephone numbers for police, fire, and emergency medical services (EMS) personnel. 4.  Clarify who has referred the family to you and why. 5.  Consider what is usually expected of a nurse in working with a family that has been referred for these health concerns (e.g., postpartum visit), and clarify the purposes of this home visit. 6.  Consider whether any special safety precautions are required. 7.  Have a plan of activities for the home visit time (see Box 11-3 ). 8.  Have equipment needed for hand-washing, physical assessment, and direct care interventions, or verify that client has the equipment in the home. 9.  Take any data assessment or permission forms that are needed. 10.  Have information and teaching aids for health teaching, as appropriate. 11.  Have information about community resources, as appropriate. 12.  Have gasoline in your automobile or money for public transportation. 13.  Leave an itinerary with the agency personnel or faculty. 14.  Approach the visit with self-confidence and caring. The visit begins with a reintroduction and a review of the plan for the day; the nurse must assess what has happened with the family since the last encounter. At this point, the nurse may renegotiate the plan for the visit and implement it. The end of the visit consists of summarizing, preparing for the next encounter, and leave-taking. Box 11-3 describes the community/public health nurse’s typical activities during a home visit. Box 11-3 Nursing Activities During Three Phases of a Home Visit Initiation Phase of Home Visit 1.  Knock on door, and stand where you can be observed if a peephole or window exists. 2.  Identify self as [name], the nurse from [name of agency]. 3.  Ask for the person to whom you were referred or the person with whom the appointment was made. 4.  Observe environment with regard to your own safety. 5.  Introduce yourself to persons who are present and acknowledge them. 6.  Sit where family directs you to sit. 7.  Discuss purpose of visit. On initial visits, discuss services to be provided by agency. 8.  Have permission forms signed to initiate services. This activity may be done later in the home visit if more explanation of services is needed for the family to understand what is being offered. Implementation Phase of Home Visit 9.  Complete health assessment database for the individual client. 10.  On return visits, assess for changes since the last encounter. Explore the degree that family was able to follow up on plans from previous visit. Explore barriers if follow-up did not occur. 11.  Wash hands before and after conducting any physical assessment and direct physical care. 12.  Conduct physical assessment, as appropriate, and perform direct physical care. 13.  Identify household members and their health needs, use of community resources, and environmental hazards. 14.  Explore values, preferences, and clients’ perceptions of needs and concerns. 15.  Conduct health teaching as appropriate, and provide written instructions. Include any safety recommendations. 16.  Discuss any referral, collaboration, or consultation that you recommend. 17.  Provide comfort and counseling, as needed. Termination Phase of Home Visit 18.  Summarize accomplishments of visit. 19.  Clarify family’s plan of care related to potential health emergency appropriate to health problems. 20.  Discuss plan for next home visit and discuss activities to be accomplished in the interim by the community/public health nurse, individual client, and family members. 21.  Leave written identification of yourself and agency, with telephone numbers. Characteristics of Relationships with Families Some differences are worth discussing in nurses’ relationships with families compared with those with individual clients in hospitals. The difference that usually seems most significant to the nurse who is learning to make home visits is the fact that the nurse has less control over the family’s environment and health-related behavior ( McNaughton, 2000 ). The relationship usually extends for a longer period. A more interdependent relationship develops between the community/public health nurse and the family throughout all steps of the nursing process. Families Retain Much Control The family can control the nurse’s entry into the home by explicitly refusing assistance, establishing the time of the visit, or deciding whether to answer the door. Unlike hospitalized clients, family members can just walk away and not be home for the visit. One study of home visits to high-risk pregnant women revealed that younger and more financially distressed women tended to miss more appointments for home visits ( Josten et al., 1995 ). Being rejected by the family is often a concern of nurses who are learning to conduct home visits. As with any relationship, anxiety can exist in relation to meeting new, unknown families. Families may actually have similar feelings about meeting the nurse and may wonder what the nurse will think of them, their lifestyle, and their health care behavior. A helpful practice is to keep your perspective; if the clients are home for your visit, they are at least ambivalent about the meeting! If they are at home to answer the door, they are willing to consider what you have to offer. Most families involved with home care of the ill have requested assistance. Because only a few circumstances exist (as previously discussed) in which nursing care can be forced on families, the nurse can view the home visit as an opportunity to explore voluntarily the possibility of engaging in relationships ( Byrd, 1995 ). The nurse is there to offer services and engage the family in a dialogue about health concerns, barriers, and goals. As with all nurse–client relationships, the nurse’s commitment, authenticity, and caring constitute the art of nursing practice that can make a difference in the lives of families. Just as not all individuals in the hospital are ready or able to use all of the suggestions made to them, families have varying degrees of openness to change. If after discussing the possibilities the family declines either overtly or through its actions, the nurse has provided an opportunity for informed decision making and has no further obligation. Goals of Nursing Care Are Long Term A second major difference in nurse relationships with families is that the goals are usually more long term than are those with individual clients in hospitals. Clients may be in hospice programs for 6 months. A family with a member who has a recent diagnosis of hypertension may take 6 weeks to adjust to medications, diet, and other lifestyle changes. A school-aged child with a diagnosis of attention deficit disorder may take as long as half the school year to show improvement in behavior and learning; sometimes, a year may be required for appropriate classroom placement. For some nurses, this time frame is judged to be slow and tedious. For others, the time frame is seen as an opportunity to know a family in more depth, share life experiences over time, and see results of modifications in nursing care. For nurses who like to know about a broad range of health and nursing issues, relationships with families stimulate this interest. Having had some experience in home visiting is helpful for nurses who work in inpatient settings; it allows them to appreciate the scope and depth of practice of community/public health nurses who make home visits as a part of their regular practice. These experiences can sensitize hospital nurses to the home environments of their clients and can result in better hospital discharge plans and referrals. Because ultimate goals may take a long time to achieve, short-term objectives must be developed to achieve long-term goals. For example, a family needs to be able to plan lower-calorie menus with sufficient nutrients before weight loss is possible; a parent may need to spend time with a child daily before unruly behavior improves. Nursing interventions in a hospital setting become short-term objectives for client learning and mastery in the home setting. In an inpatient setting, giving medications as prescribed is a nursing action. In the home, the spouse giving medications as prescribed becomes a behavioral objective for the family; the related nursing action is teaching. Human progress toward any goal does not usually occur at a steady pace. For example, you may start out bicycling faithfully three times a week and give up abruptly. Similarly, clients may skip an insulin dose or an oral contraceptive. A family may assertively call appropriate community agencies, keep appointments, and stop abruptly. Families can be committed to their own health and well-being and yet not act on their commitment consistently. Recognizing that setbacks and discouragement are a part of life allows the community/public health nurse to be more accepting of reality and have the objectivity to renegotiate goals and plans with families. Box 11-4 includes evidence-based ways to foster goal accomplishment. Box 11-4 Best Practices in Fostering Goal Accomplishment With Families 1.  Share goals explicitly with family. 2.  Divide goals into manageable steps. 3.  Teach the family members to care for themselves. 4.  Do not expect the family to do something all of the time or perfectly. 5.  Be satisfied with small, subtle changes. 6.  Be flexible. Changes are sometimes subtle or small. Success breeds success, at least motivationally. The short-term goals on which everyone has agreed are important to make clear so that the nurse and the family members have a common basis for evaluation. Goals can be set in a logical sequence, in small steps, to increase the chance of success. In an inpatient setting, the skilled nurse notices the subtle changes in client behavior and health status that can warn of further disequilibrium or can signal improvement. Similarly, during a series of home visits, the skilled nurse is aware of slight variations in home management, personal care, and memory that may presage a deteriorating biological or social condition. Nursing Care Is More Interdependent with Families Because families have more control over their health in their own homes and because change is usually gradual, greater emphasis must be placed on mutual goals if the nurse and family are to achieve long-term success. Except in emergency situations, the client determines the priority of issues. A parent may be adamant that obtaining food is more important than obtaining their child’s immunization. A child’s school performance may be of greater concern to a mother than is her own abnormal Papanicolaou (Pap) smear results. Failure of the nurse to address the family’s primary priority may result in the family perceiving that the nurse does not genuinely care. At times, the priority problem is not directly health related, or the solution to a health problem can be handled better by another agency or discipline. In these instances, the empathic nurse can address the family’s stress level, problem-solving ability, and support systems and make appropriate referrals. When the nurse takes time to validate and discuss the primary concern, the relationship is enhanced. Families are sometimes unaware of what they do not know. The nurse must suggest health-related topics that are appropriate for the family situation. For example, a young mother with a healthy newborn may not have thought about how to determine when her baby is ill. A spouse caring for his wife with Alzheimer disease may not know what safety precautions are necessary. Community/public health nurses seek to enhance family competence by sharing their professional knowledge with families and building on the family’s experience ( Reutter & Ford, 1997 ; SmithBattle, 2009 ). Flexibility is a key. Because visits occur over several days to months, other events (e.g., episodic illnesses, a neighbor’s death, community unemployment) can impinge on the original plan. Family members may be rehospitalized and receive totally new medical orders once they are discharged to home. The nurse’s clarity of purpose is essential in identifying and negotiating other health-related priorities after the first concerns have been addressed ( Monsen, Radosevich, Kerr, & Fulkerson, 2011 ). Increasing nurse–family relatedness What promotes a successful home visit? What aspects of the nurse’s presence promote relatedness? What structures provide direction and flexibility? The nursing process provides a general structure, and communication is a primary vehicle through which the nursing process is manifested. The foundation for both the nursing process and communication is relatedness and caring ( ANA, 2003 ; McNaughton, 2005 ; Roach, 1997 ; SmithBattle, 2009 ; Watson, 2002 ; Watson, 2005 ). Fostering a Caring Presence Nursing efforts are not always successful. However, by being concerned about the impact of home visits on the family and by asking questions regarding her or his own motivations, the nurse automatically increases the likelihood that home visits will be of benefit to the family. The nurse is acknowledging that the intention is for the relationship to be meaningful to both the nurse and the family. Building and preserving relationships is a central focus of home visiting and requires significant effort ( Heaman et al., 2007 ; McNaughton, 2000 , 2005 ). The relatedness of nurses in community health with clients is important ( Goldsborough, 1969 ; SmithBattle, 2009 ; Zerwekh, 1992 ). Involvement, essentially, is caring deeply about what is happening and what might happen to a person, then doing something with and for that person. It is reaching out and touching and hearing the inner being of another…. For a nurse–client relationship to become a moving force toward action, the nurse must go beyond obvious nursing needs and try to know the client as a person and include him in planning his nursing care. This means sharing feelings, ideas, beliefs and values with the client…. Without responsibility and commitment to oneself and others…[a person] only exists. It is through interaction and meaningful involvement with others that we move into being human ( Goldsborough, 1969 , pp. 66-68). Mayers (1973, p. 331) observed 16 randomly selected nurses during home visits to 37 families and reported that “regardless of the specific interaction style [of each nurse], the clients of nurses who were client-focused consistently tended to respond with interest, involvement and mutuality.” A client-focused nurse was observed as one who followed client cues, attempted to understand the client’s view of the situation, and included the client in generating solutions. Being related is a contribution that the nurse can make to the family, independent of specific information and technical skills, a contribution that students often underestimate. Although being related is necessary, it is inadequate in itself for high-quality nursing. A community/public health nurse must also be competent. Community/public health nursing also depends on assessment skills, judgment, teaching skills, safe technical skills, and the ability to provide accurate information. As a community/public health nurse’s practice evolves, tension always exists between being related and doing the tasks. In each situation, an opportunity exists to ask, “How can I express my caring and do (perform direct care, teach, refer) what is needed?” Barrett (1982) and Katzman and colleagues (1987) reported on the differences that students actually make in the lives of families. Barrett (1982) demonstrated that postpartum home visits by nursing students reduced costly postpartum emergency department and hospital visits. Katzman and co-workers (1987) considered hundreds of visits per semester made by 80 students in a southwestern state to families with newborns, well children, pregnant women, and members with chronic illnesses. Case examples describe how student enthusiasm and involvement contributed to specific health results. Everything a nurse has learned about relationships is important to recall and transfer to the experience of home visiting. Carl Rogers (1969) identified three characteristics of a helping relationship: positive regard, empathy, and genuineness. These characteristics are relevant in all nurse–client relationships, and they are especially important when relationships are initiated and developed in the less-structured home setting. Presence means being related interpersonally in ways that reveal positive regard, empathy, genuineness, and caring concern. How is it possible to accept a client who keeps a disorderly house or who keeps such a clean house that you feel as if you are contaminating it by being there? How is it possible to have positive feelings about an unmarried mother of three when you and your partner have successfully avoided pregnancy? Having positive regard for a family does not mean giving up your own values and behavior (see Chapter 10 ). Having positive regard for a family that lives differently from the way you do does not mean you need to ignore your past experiences. The latter is impossible. Rather, having positive regard means having the ability to distinguish between the person and her or his behavior. Saying to yourself, “This is a person who keeps a messy house” is different from saying, “This person is a mess!” Positive regard involves recognizing the value of persons because they are human beings. Accept the family, not necessarily the family’s behavior. All behavior is purposeful; and without further information, you cannot determine the meaning of a particular family behavior. Positive regard involves looking for the common human experiences. For example, it is likely that both you and client family members experience awe in the behavior of a newborn and sadness in the face of loss. Empathy is the ability to put yourself in someone else’s shoes and to be able to walk in her or his footsteps so as to understand her or his journey. “Empathy requires sensitivity to another’s experience…including sensing, understanding, and sharing the feelings and needs of the other person, seeing things from the other’s perspective” according to Rogers (cited in Gary & Kavanagh, 1991 , p. 89). Empathy goes beyond self and identity to acknowledge the essence of all persons. It links a characteristic of a helping relationship with spirituality or “a sense of connection to life itself” ( Haber et al., 1987 , p. 78). Empathy is a necessary pathway for our relatedness. However, what does understanding another person’s experience mean? More than emotions are involved. A person’s experience includes the sense that she or he makes of aspects of human existence ( SmithBattle, 2009 ; van Manen, 1990 ). Being understood means that a person is no longer alone ( Arnold, 1996 ). Being understood provides support in the face of stress, illness, disability, pain, grief, and suffering. When a client feels understood in a nurse–client partnership (side-by-side relationship), the client’s experience of being cared for is enhanced ( Beck, 1992 ). To understand another person’s experience, you must be able to imagine being in her or his place, recognize commonalities among persons, and have a secure sense of yourself ( Davis, 1990 ). Being aware of your own values and boundaries is helpful in retaining your identity in your interactions with others. To understand another individual’s experience, you must also be willing to engage in conversation to negotiate mutual definitions of the situation. For example, if you are excited that an older person is recovering function after a stroke, but the person’s spouse sees only the loss of an active travel companion, a mutual definition of the situation does not exist. Empathy will not occur unless you can also understand the spouse’s perspective. As human beings, we all like to perceive that we have some control in our environment, that we have some choice. We avoid being dominated and conned. The nurse’s genuineness facilitates honesty and disclosure, reduces the likelihood that the family will feel betrayed or coerced, and enhances the relationship. Genuineness does not mean that you speak everything that you think. Genuineness means that what you say and do is consistent with your understanding of the situation. The nurse can promote genuine self-expression in others by creating an atmosphere of trust, accepting that each person has a right to self-expression, “actively seeking to understand” others, and assisting them to become aware of and understand themselves ( Goldsborough, 1969 , p. 66). When family members do not believe that being genuine with the nurse is safe, they may tell only what they think the nurse would like to hear. This action makes developing a mutual plan of care much more difficult. The reciprocal side of genuineness is being willing to undertake a journey of self-expression, self-understanding, and growth. Tamara, a recent nursing graduate, wrote about her growing self-responsibility: “Although I felt out of control, I felt very responsible. I took pride in knowing that these families were my families, and I was responsible for their care. I was responsible for their health teaching. This was the first semester where there was no a faculty member around all day long. I feel that this will help me so much as I begin my nursing career. I have truly felt independent and completely responsible for my actions in this clinical experience.” This student, who preferred predictable environments, was able to confront her anxiety and anger in environments in which much was beyond her control. A mother was not interested in the student’s priorities. A family abruptly moved out of the state in the middle of the semester. Nonetheless, the student was able to respond in such circumstances. She became more responsible, and she was able to temper her judgment and work with the mother’s concern. When the family moved, the student experienced frustration and anger that she would not see the “fruits of her labor” and that she would “have to start over” with another family. However, her ability to respond increased because of her commitment to her own growth, relatedness with families, and desire to contribute to the health and well-being of others. In a context of relating with and advocating for the family, the relationship becomes an opportunity for growth in both the nurse’s and the family’s lives ( Glugover, 1987 ). Imagine standing side-by-side with the family, being concerned for their well-being and growth. Now imagine talking to a family face-to-face, attempting to have them do things your way. The first image is a more caring and empathic one. Creating Agreements for Relatedness How can communications be structured to increase the participation of family members? Without the family’s engagement, the community/public health nurse will have few positive effects on the health behavior and health status of the family and its members. Nurses are expert in caring for the ill; in knowing about ways to cope with illness, to promote health, and to protect against specific diseases; and in teaching and supporting family members. Family members are experts in their own health. They know the family health history, they experience their health states, and they are aware of their health-related concerns. Through the nurse–family relationship, a fluid process takes place of matching the family’s perceived needs with the nurse’s perceptions and professional judgments about the family’s needs. Paradoxically, the more skilled the nurse is in forgetting her or his own anxiety about being the good nurse, the more likely the nurse is to listen to the family members, validate their reality, and negotiate an adequate, effective plan of care. One study of home visits revealed that more than half of the goals stated by public health nurses to the researcher could not be detected, even implicitly, during observations of the home visits. Therefore, half the goals were known only to the nurse and were, therefore, not mutual. The more specifically and concretely the goals were stated by the nurse to the researcher, the greater would be the likelihood that the clients understood the nurse’s purposes ( Mayers, 1973 ). To negotiate mutual goals, the client needs to understand the nurse’s purposes. The initial letter, telephone call, or home visit is the time to share your ideas with the family about why you are contacting them. During the first interpersonal encounter by telephone or home visit, explore the family members’ ideas about the purpose of your visits. This phase is essential in establishing a mutually agreed on basis for a series of encounters. As a result of her qualitative research study of maternal-child home visiting, Byrd (2006, p. 271) stated that “people enter…relationships with the expectation of receiving a benefit” that may be information, status, service, or goods. Byrd asserted that it is important for nurses to create client expectations through previsit publicity about (marketing) home-visiting programs. Also it is essential to understand the expectations of the specific persons being visited. Family members may have had previous relationships with community/public health nurses and students. Family members may be able to share such information as what they found to be most helpful, why they are willing to work with a nurse or student again, and what goals they have in mind. Other families who have had no prior experience with community/public health nurses may not have specific expectations. Asking is important. A contract is a specific, structured agreement regarding the process and conditions by which a health-related goal will be sought. In the beginning of most student learning experiences, the agreement usually entails one or more family members continuing to meet with the nursing student for a specific number of visits or weeks. Initially, specific goals and the nurse’s role regarding health promotion and illness prevention may be unclear. (If this role was already clear, undergoing a period of study and orientation would be unnecessary.) Initially, the agreement may be as simple as, “We will meet here at your house next Tuesday at 11:00  AM until around noon to continue to discuss what I can offer related to your family’s health and what you’d like. We can get to know each other better. We can talk more about how the week has gone for you and your family with your new baby.” These statements are the nurse’s oral offer to meet under specific conditions of time and place. The process of mutual discussion is mentioned. The goals remain general and implicit: fostering the family’s developmental task of incorporating an infant and fostering family–nurse relatedness. For the next week’s contract to be complete, the family member or members would have to agree. The most important element initially is whether agreement about being present at a specific time and place can be reached. If 11:00  AM is not workable for the family, would another time during the day when you both are available be mutually agreeable? For families who do not focus as much on the future, a community/public health nurse needs to be more flexible in scheduling the time of each visit. The word contract often implies legally binding agreements. This is not true of nurse–client contracts. Nurses are legally and ethically bound to keep their word in relation to nursing care; clients are not legally bound to keep their agreements. However, establishing a mutual agreement for relating increases the clarity of who will do what, when, where, for what purposes, and under what conditions. Because of some people’s negative response to the word contract, agreement or discussion of responsibilities may be better. An agreement may be oral or written. For some families, written agreements, especially early in the relationship, may be perceived as a threat. For example, a family that has been conned by a household repair scheme may be very suspicious of written agreements. Family members who are not legal citizens may not want to sign an agreement for fear that if it is not kept they will be punished. Do not push for a written agreement if the family is uncomfortable. If you do notice such discomfort, this may be a good opportunity to explore their fears. Written agreements are required when insurance is paying for the care provided by nurses working with home health agencies and to comply with the Health Insurance Portability and Accountability Act (HIPAA). Helgeson and Berg (1985) describe factors affecting the contracting process by studying a small convenience sample of 15 community/public health nursing students and 12 client responses. Of the 11 students who introduced the idea of a contract to clients, all did so between the second and the fourth visits of a 16-week series of visits; 9 students did so orally rather than in writing. No specific time was the best. Eight clients were very receptive to the idea because they liked the idea of establishing goals to work toward and felt the contract would serve as a reminder of their responsibility. The very process of developing a draft agreement to present to families provides the novice practitioner with an increased focus of care, clarity of nurse and family responsibilities and activities, and a basis from which to negotiate modifications in client behaviors ( Helgeson & Berg, 1985 ; Sheridan & Smith, 1975 ). The Home Visiting Evaluation Tool in Figure 11-3 lists nurse behaviors that are appropriate for home visits, especially initial home visits and those early in a series of home visits. Nurses can use this list as a preplanning tool to identify their readiness to conduct a specific home visit. Additionally, students and community/public health nurses have used the tool to evaluate initial home visits and identify their behaviors that were omitted and needed to be included on the second home visits. The tool also has been used jointly as an evaluation tool by nurses and supervisors and students and faculty. Figure 11-3 Home Visiting Evaluation Tool. (From Chichester, M., & Smith, C. [1980]. Home visiting evaluation tool [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.)

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Direct Service Providers for Children and Families: Information for Home Visitors

How home visitors can protect themselves and their clients from COVID-19 and other diseases that can be spread from person to person.

• Direct Service Providers
• People with Disabilities
• Group Homes for People with Disabilities

Home-visiting professionals, or home visitors, provide many needed services directly to children and families in their home. These direct service providers can include maternal, infant, early childhood, and early intervention home visitors. They also may be teachers and therapists who provide needed services for infants, children, and teens, including those with disabilities. When in-person services are delivered, they are often done in close and consistent contact with the clients. This means that it is important to use prevention strategies to protect the home visitor and the family from diseases that can be spread from person to person, such as COVID-19, but also flu, colds, and other respiratory or gastrointestinal illnesses. In addition, home visitors are trusted sources of information and support for families, particularly those who experience health inequity . This page provides an overview of how home visitors can protect themselves and their clients during home visits.

Strategies to prevent the spread of COVID-19

With current high uptake of COVID-19 vaccination and high levels of population immunity from both vaccination and infections, the risk of medically significant disease, hospitalization, and death from COVID-19 is greatly reduced for most people. At the same time, we know that some people and communities, such as our oldest citizens, people who are immunocompromised, and people with disabilities, are more likely to get severely ill and face challenging decisions navigating a world with COVID-19.

People who are up to date on COVID-19 vaccines have much lower risk of severe illness and death from COVID-19 than unvaccinated people. However, many home visitors work with children who are not yet eligible for vaccination. When making decisions about preventive behaviors in addition to vaccination, people should consider the COVID-19 Community Level in the county . These levels show the degree of risk (low, medium, high) and describe the prevention strategies that are recommended for each level. Prevention strategies — like staying up to date on vaccines, screening testing, ventilation, and wearing masks — can help limit severe disease and reduce the potential for strain on the healthcare system. For home visitors who work with children, it may not be feasible to use all recommended prevention strategies. Therefore, particularly in communities with medium or high COVID-19 levels, home visitors should use multiple layers of recommended COVID-19 strategies to the extent possible  while also following any applicable guidance from regulatory agencies and state and local public health departments.

The following information is a brief overview of strategies that home visitors can use when working with children and families. Detailed information about ways home visitors can protect themselves is in the COVID-19 Guidance for Direct Service Providers (cdc.gov) and in the COVID-19 Guidance for Operating Early Care and Education/Child Care (ECE) Programs (cdc.gov)

Ways home visitors can protect themselves and the families they serve:

1. vaccination.

Vaccination is the leading public health prevention strategy to end the COVID-19 pandemic. COVID-19 vaccines available in the United States are effective at protecting people from getting seriously ill, being hospitalized, and dying from COVID-19. As with vaccines for other diseases, people who are up to date with their COVID-19 vaccines  are best protected.

Home visitors can protect themselves, their own families, and the families they care for by staying up to date with all vaccinations, including COVID-19 vaccines. As trusted professionals who know their families well, home visitors can play a role in helping families learn about the importance of vaccines and about supporting children’s healthy development by keeping up to date on all well visits and preventive screenings, such as screening for developmental delays and lead poisoning . They can help connect the family to a regular primary healthcare provider who provides consistent and supportive health care and serves as the family’s medical home . They can remind families that children should get all routine vaccinations to help protect themselves and others from vaccine-preventable diseases , and that family members who are up to date on all vaccines protect children who are not yet old enough to get all vaccines.

Families who are not up to date with all vaccinations may have questions and concerns about the vaccines. Home visitors can promote vaccines by:

• Encouraging families to connect with a regular primary healthcare provider and stay up-to-date on COVID-19 vaccines.
• Sharing information with parents and caregivers to answer questions and help with any worries and concerns: COVID-19 Vaccines for Children and Teens, Frequently Asked Questions about COVID-19 Vaccination in Children , and Resources to Promote the COVID-19 Vaccine for Children & Teens .
• Using the strategies that health care providers use to help with worries and concerns: Talking with Patients about COVID-19 Vaccination , Frequently Asked Questions about COVID-19 Vaccination .
• Helping families who have worries and fears about needles for themselves and their children: Needle Fears and Phobia – Find Ways to Manage .
• Finding ways to support COVID-19 vaccination in their ECE programs .

2. Ventilation

Improving ventilation is an important COVID-19 prevention strategy that can reduce the number of virus particles in the air. Along with other preventive strategies , bringing fresh outdoor air into a building helps keep virus particles from concentrating inside. Home visitors can improve ventilation or ask families to improve ventilation during the visit by

• Opening multiple doors and windows, if feasible.
• Using child-safe fans to increase the effectiveness of open windows.
• Using the exhaust fan  in the kitchen or bathroom to increase air flow, particularly if opening windows is not possible.
• Using portable HEPA air cleaners .
• Visiting with the child outdoors when possible.

Learn more about encouraging families to improve the ventilation in their home .

3. Hygiene: Respiratory Etiquette, Handwashing, Cleaning, Sanitizing, and Disinfecting

Home visitors can limit the spread of illnesses by following all guidance on cleaning, sanitizing, and disinfecting. During home visits, many activities may involve touching children, and infants and toddlers often need to be held.  For COVID-19 in general, cleaning once a day is usually enough to sufficiently remove potential virus that may be on surfaces. However, in addition to cleaning for COVID-19, home visitors should practice and encourage families to practice respiratory etiquette and recommended procedures for cleaning, sanitizing, and disinfection , such as after diapering , feeding , and exposure to bodily fluids. See more information about cleaning and sanitizing toys .

Home visitors can use the following strategies:

• Use respiratory etiquette , including covering coughs and sneezes and washing hands immediately after blowing the nose, coughing, or sneezing.
• If handwashing is not possible, use hand sanitizer containing at least 60% alcohol. Hand sanitizers should be stored up, away, and out of sight of young children and should be used only with adult supervision for children under 6 years of age or for children with certain disabilities that make it hard for the child to use hand sanitizer safely on their own.
• Avoid touching the eyes while holding, washing, or feeding a child.
• Wear disposable gloves during activities such as dressing, bathing/showering, toileting, feeding. Safely dispose of gloves after use. Wash hands before and after taking off disposable gloves. If gloves are unavailable, wash hands immediately after.
• Change clothes right away if body fluids get on them, whenever possible, and then rewash hands. Launder work uniforms or clothes after each use with the warmest appropriate water setting for the items and dry items completely.
• Wash anywhere that was in contact with a child’s body fluids and follow recommendations on  cleaning and sanitizing toys, other learning tools , and assistive devices, particularly if they were in contact with body fluids.
• Follow recommendations for cleaning and disinfecting the home  if someone is sick, or tests positive for COVID-19.

When people ages 2 and older wear a well-fitting mask correctly and consistently, they protect others as well as themselves  from infections that are spread through the air or through respiratory droplets. Consistent and correct mask use is recommended in public settings in communities with high COVID-19 Community Levels , and around people at high risk for severe disease in communities with medium COVID-19 Community Levels . At all COVID-19 Community Levels, people can wear a mask based on personal preference, informed by personal level of risk. People with symptoms of COVID-19, people with a positive COVID-19 test results who are around other people, and people who are quarantining because of a close contact, should wear a mask.

Masks should not be worn by children under age 2. Some older children or adults cannot wear a mask, or cannot safely wear a mask , because of a disability as defined by the Americans with Disabilities Act (ADA) (42 U.S.C. 12101 et seq.).

When choosing a mask , home visitors can consider fit, comfort, and the special needs of the people around them. To facilitate learning and social and emotional development, consider wearing a clear mask or cloth mask with a clear panel when interacting with young children, children learning to speak or read, children learning another language, or when interacting with people who rely on reading lips. Generally, vinyl and non-breathable materials are not recommended for masks . However, for ease of lip-reading, this is an exception to that general guidance.

5. Physical Distancing

It is generally recommended that people maintain a distance of at least 6 feet from persons who are sick with COVID-19. However, maintaining physical distance between a home visitor and their clients is often not feasible during home visiting, especially during certain activities such as physical therapy, feeding, holding/comforting, and among younger children in general. When it is not possible to maintain physical distance in home visiting settings, it is especially important to layer multiple prevention strategies, such as masking indoors, improved ventilation, handwashing, covering coughs and sneezes, and regular cleaning to help reduce COVID-19 transmission risk.

6. Isolation and Quarantine

People who are confirmed to have COVID-19 or are showing symptoms of COVID-19 need to stay home (known as isolation) regardless of their vaccination status. This includes

• People who have a positive viral test  for COVID-19, whether or not they have symptoms .
• People with symptoms  of COVID-19, including people who are awaiting test results or have not been tested. People with symptoms should isolate even if they do not know if they have been in close contact with someone with COVID-19.

People who come into close contact  with someone with COVID-19 should quarantine  if they have not had confirmed COVID-19 within the last 90 days and are in one of the following groups:

• Infants and young children who are not eligible for vaccination based on age .
• Staff and older children who are not up to date with COVID-19 vaccines (have not received all recommended COVID-19 vaccines, including any booster dose(s) when eligible ).

Home visitors can encourage families to monitor children at home for fever (a temperature of 100.4 ºF (38.0 ºC)  or other signs of illnesses that could be spread to others [PDF – 1 page] , including COVID-19, and adjust visit schedules if needed. Services may be provided virtually during quarantine or isolation if feasible.

Learn more about CDC guidance on COVID-19 Quarantine and Isolation  and about making decisions about the length of quarantine and isolation for young children:  Isolation and Quarantine in Early Care and Education (ECE) Programs .

7. Mental Health Support

Taking care of children requires a lot of effort and includes many challenges. CDC provides resources to support the mental health of home visitors and the families they serve, for example:

• Stress and Coping
• How Right Now – Finding What Helps with Emotional Well-Being and Resilience
• Tips for Promoting School Employee Wellness
• Taking Care of Your Emotional Health
• Learn About Children’s Mental Health
• Mental Health
• Occupational Health and Safety
• COVID-19 Guidance for Direct Service Providers
• Vaccinating Children with Disabilities Against COVID-19
• Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program | MCHB (hrsa.gov)
• Home Visiting | The Administration for Children and Families (hhs.gov)
• Health Tips for Home Visitors to Prevent the Spread of Illness (hhs.gov) [PDF – 11 pages]
• COVID-19 Information for Health Centers and Partners | Bureau of Primary Health Care (hrsa.gov)
• Learn About Child Development
• “Learn the Signs. Act Early.” 

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Revisiting Home Visiting: Summary of a Workshop (1999)

Chapter: challenges faced by home visiting programs, challenges faced by home visiting programs.

The workshop participants identified several critical challenges that face virtually all home visiting programs. They include family engagement, staffing, cultural and linguistic diversity, and conditions, such as maternal depression, that are experienced by many of the participating families.

Family Engagement

The engagement of families in home visitation programs includes the combined challenges of getting families to enroll, keeping them in the program, and sustaining their interest and commitment during and between visits. Parental engagement is essential to the effectiveness of programs and to the validity of research efforts. For example, ongoing reanalyses conducted by Margaret Burchinal, of the University of North Carolina at Chapel Hill, Jeanne Brooks-Gunn, of Columbia University’s Teachers College, and Michael Lopez, of the Administration on Children, Youth, and Families, of data from the Comprehensive Child Development Program revealed that families at two sites that successfully provided more home visits per participating family showed significant effects on child cognitive outcomes compared with control group families; families at sites that offered less home visiting were significantly below the control group in child outcomes. As noted in the Spring/Summer 1999 issue of The Future of Children, programs “rely to some extent upon changes in parental behavior to generate changes in children’s health and development. If parent involvement flags between visits, then changes in children’s behavior will be much harder to achieve” (Gomby et al., 1999). This general conclusion was repeated throughout the workshop by both practitioners and researchers.

Mildred Winter, of the Parents as Teachers National Center, Inc., cited one of the main barriers to the success of home visiting programs to be the lack of motivation of parents to commit to the program. Many others acknowledged that home visiting is a relatively invasive procedure that entails a huge commitment of time and energy on behalf of parents, primarily mothers. It is therefore not surprising that The Future of Children review indicated that families typically received only half the number of visits prescribed. “The consistency with which this occurs across the models suggests that this is a real phenomenon in implementation of home visiting programs” (Gomby et al., 1999). Even when motivated and eager to participate, as noted by workshop participants, families miss visits because of difficulties associated with rescheduling, given busy families and home visitors with large caseloads.

Workshop participants were in agreement that one of the keys to keeping the family engaged throughout the duration of the program is a good relationship between the home visitor and the family. In the Infant Health and Development Program, home visitors’ ratings of parental engagement in the visits were highly predictive of program effects. As noted by Janet Dean, of the Community Infant Program in Boulder, Colorado, “Home visitors need to create a good relationship -- a safe context -- with the family before they can help the family. ” Although some programs target children directly, most home visiting programs are premised on the belief that parents are effective mediators of change in their children, and therefore target the parents directly. Despite the positive findings of some evaluations (such as the reanalysis of data from the Comprehensive Child Development Program), Brooks-Gunn noted that, in general, there is

not much evidence to back up the belief in this premise, nor is there a good appreciation for the difficulty of creating sufficient behavioral change in parents to actually improve child functioning. Workshop participants were in agreement that what is needed is better measurement and understanding of the relationship between the home visitor and the mother.

Attrition is endemic to home visitation. Many families not only miss visits, but also leave the program altogether before it is scheduled to end. For example, of the programs reviewed in Spring/Summer 1999 issue of The Future of Children, attrition rates ranged from 20 to 67 percent. Anne Duggan, of Johns Hopkins University’s School of Medicine, reported that the program ’s approach to retention can affect attrition rates. The three Hawaii Healthy Start programs that she studied had highly variable attrition rates (from 38 to 64 percent over one year). The program with the lowest attrition rate actively and repeatedly tracked down families that tried to drop out, whereas the program with the highest attrition rate assumed that if the parent did not want to be involved, it was not the program’s responsibility to push her.

What can programs do to increase engagement? Olds surmised that enrolling mothers into the Nurse Home Visiting Programs while they were still pregnant with their first child and therefore highly motivated to learn about effective parenting strategies improved retention rates. Another strategy, which was mentioned by many at the workshop, is to make parents part of the program planning process. This may help parents “buy into” the program from the beginning, in addition to ensuring that the program really addresses the needs of the families it intends to serve. Parents need to believe that the home visiting services will help them accomplish goals that they have set for themselves and that warrant an extensive commitment. Answering the question of how to improve engagement is still a big challenge and an issue that needs much more systematic examination as part of implementation studies.

Virtually every speaker at the workshop commented that the home visitor ’s role is critical. As noted by Melmed, “Any service program is only as good as the people who staff it.” In the case of home visiting, the demands on the staff are diverse and often stressful. They must have “the personal skills to establish rapport with families, the organizational skills to deliver the home visiting curriculum while still responding to family crises that may arise, the problem-solving skills to be able to address issues that families present in the moment when they are presented, and the cognitive skills to do the paperwork that is required” (Gomby et al., 1999). Workshop participants identified challenges associated with finding appropriate staff, retaining staff, offering the necessary training and supervision, and matching staff to families with differing needs and predilections, some of which are culturally based and others that are not.

Program designers differ in their views about appropriate staff. Some programs, such as the Nurse Home Visitation Program, rely heavily on professionals (people with degrees in fields relevant to home visiting, such as nursing), but the majority of home visiting programs use paraprofessionals who often come from the community being served and typically have less formal education or training than professional staff beyond that provided by the program. There is an active debate in home visiting over which type of staff is most effective at delivering the curriculum and achieving results. The Nurse Home Visitation Program is based on the premise

that nurses are more effective home visitors than paraprofessionals. An evaluation of the Nurse Home Visitation Program in Denver, Colorado, found that families visited by nurses have a lower rate of attrition and complete more visits than families visited by paraprofessionals, even though the paraprofessionals worked just as hard as the nurses to retain families. Olds speculated that the families conferred greater authority upon the nurses and that the nurses were better equipped to respond to the mothers’ needs and feelings of vulnerability. As a result, the mothers may have complied more willingly with the nurses ’ guidance.

Others see paraprofessionals as better than professionals at creating the essential relationship with the family, because there is less social distance between paraprofessionals and the families they serve. Pilar Baca, of the Kempe Prevention Research Center for Family and Child Health and a trainer of staff for the Nurse Home Visitation Program, noted that the choice of staff is really a question of “for whom, for what?” She argued for the development of “robust paraprofessional models” as an alternative to assuming that professionals will be the preferred or even feasible option for all circumstances.

Regardless of the prior background of the visitors, they invariably face extremely complex issues when working with families and require appropriate preparation, ongoing information, and constant feedback to perform their jobs well. Many at the workshop commented on the need for more extensive and higher-level staff training, both before the home visitor begins working with families as well as during the course of their employment. Two aspects of training were mentioned often at the workshop. The first pertained to ensuring that the home visitors are well versed and accepting of the desired objectives and the philosophy of the particular home visiting program that they are responsible for implementing. The second had to do with the relatively poor ability of some home visitors to recognize conditions such as maternal depression, substance abuse, and domestic violence that interfere with program implementation, family engagement, and effectiveness.

Staff turnover is a significant problem for many programs. For example, the Nurse Home Visitation Program in Memphis had a 50 percent turnover rate in nurses due to a nursing shortage in the community. Other programs relying more on paraprofessionals reported even higher turnover rates. The Nurse Home Visitation Program in Denver, for example, had no turnover among the nurses who were providing home visits, but substantial turnover among the paraprofessionals. The specific impact of turnover on the effectiveness of programs is unknown, but it is likely to present a real problem since the quality of the home visitor/mother relationship is so predictive of program efficacy.

In this area, home visiting may be able to learn from the experiences of the child care field, since both have similar levels of turnover. In the child care field, turnover has been linked to the low wages earned by child care workers as well as to the quality of care received by children and families. Home visiting positions are also typically low-paying and stressful, and it makes sense that many staff will leave if they find a better-paying opportunity. Other keys to staff retention discussed at the workshop include good supervision and good morale. Providing home-based services can be isolating for the home visitor and, as such, requires a higher, more intense level of supervision. At the same time, because supervisors do not typically accompany staff on home visits and therefore do not observe home visitors performing the intervention, it

can be difficult for them to help the home visitor reflect on and learn from their experiences. Despite these difficulties, home visitors need supervision that goes beyond “did you do your job or not” to include elements of social and emotional support, teamwork, and recognition of staff effort. Terry Carrilio, of the Policy Institute at the San Diego State University School of Social Work, aptly observed that the “process needs to reflect what you are trying to do. If a program does not treat its staffwell, how can we expect the staff to deliver a supportive service? ”

Cultural and Linguistic Diversity

Cultural and linguistic considerations are also involved in the decision of who can best deliver home visiting services, but they encompass many other complex issues as well. Home visiting programs deal with fundamental beliefs about how a parent interacts with a child. These beliefs, which are heavily imbued with cultural meaning, provide the foundation for the design and implementation of any program. As noted by Baca, for example, it is likely to be more difficult for a home visitor from a culture different from that of the family to distinguish between practices and beliefs that are culturally different and those that are culturally dysfunctional. This applies as well to evaluators. Linda Espinosa, of the Department of Curriculum and Instruction at the University of Missouri, cautioned that there are possible ripple effects when “we start changing highly personal, highly culturally embedded ways of interacting and socializing children within the family unit. We hope the effects are positive, but we cannot ignore the possibility that they could be negative.” In this context, Espinosa specifically mentioned the potential for programs to upset “the fragile balance of power within the family.”

Decisions about using bicultural and bilingual home visitors are often determined by forces beyond the control of the program. For example, the Family Focus for School Success program in Redwood City, California, chose to hire paraprofessionals because, as Espinosa described, “there were no certificated or B.A.-level people who were bilingual and bicultural and who were floating around in the community waiting to be hired.” Program developers made the decision that having bilingual and bicultural staff was more important than having professional staff. This issue creates certain challenges when programs are expanded since it may not be possible to find enough people willing to be home visitors with the necessary qualifications. The basic question, as for all interventions, is: “Do our goals and outcomes align with the hopes, dreams, and aspirations of the families we serve?”

Domestic Violence, Maternal Depression, and Substance Abuse

Three conditions that can significantly impede the capacity of a home visiting program to benefit families were identified and discussed at the workshop: domestic violence, maternal depression, and substance abuse. Home visiting programs generally set goals that are preventive in nature: to prevent child abuse and neglect, to improve the nutrition and health practices of the mother, to reduce the number of babies born with low birthweight, and to promote school readiness and prevent school failure. However, the families that are targeted by home visiting programs often experience other problems, such as maternal depression, substance abuse, and domestic violence, that need to be addressed before the prevention goals of the program can be achieved.

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What’s Happening During Home Visits? Exploring the Relationship of Home Visiting Content and Dosage to Parenting Outcomes

Peggy nygren.

1 Regional Research Institute for Human Services, Graduate School of Social Work, Portland State University, Market Center Building, Suite 900,1600 SW 4th Ave, Portland, OR 97201 USA

2 Center for Improvement of Child and Family Services, Graduate School of Social Work, Portland State University, Market Center Building, Suite 400,1600 SW 4th Ave, Portland, OR 97201 USA

Katie Winters

Anna rockhill.

Introduction Research has documented modest positive impacts of early childhood home visiting programs. However, understanding more about what home visitors do during visits and how much time they spend on specific topics may provide insight into the variability in effectiveness of services. Methods Outcome data were collected via parent survey at program enrollment and 12 months from 123 women in three MIECHV-funded home visiting models. Home visitors completed weekly home visit content and activity logs. Results Families received an average of 28 visits during the study (3.1 visits per month). Of ten content areas, the three most often discussed were early childhood development, physical care of children, and the parent–child-relationship. Multivariate regression models were used to explore the association of home visit dosage, home visit content and cumulative risk factors on parenting outcomes. Women whose visits were focused more on parenting topics reported lower parenting-related stress at follow-up compared to those whose visits had less parenting content. Additionally, higher-risk women who received greater numbers of home visits showed larger reductions in their attitudes about harsh punishment over time, compared to high-risk women with fewer home visits. Discussion Receiving home visits that emphasize parenting content may contribute to reduced parenting-related stress. For high-risk women in particular, receiving more visits overall may be important to achieving positive outcomes. Implications for practice include working to engage and retain high-risk families. Future home visiting research calls for improved methods for collecting data on content/activity during visits, the necessity for long-term follow-up, and testing for the effectiveness of varied and flexible visit schedules/content focus for women and families with trauma exposure.

Significance

While research has documented small-to-modest positive program impacts of early childhood home visiting in various models, less is known about how home visit dosage and the specific content covered during home visits influence parenting and family outcomes. Wide variations across home visiting models are found in both how many visits women receive and the type of activity during visits. Many of the women screened eligible for home visiting services are currently experiencing multiple life challenges and/or have significant trauma histories. For women and families with multiple risk characteristics, understanding how dosage and content relates to parenting outcomes is critical to improving program effectiveness and to guiding program and home visitor practices. Our work sought to address these gaps by linking detailed information about the dosage (# of visits) and content areas of home visits and risk characteristics of participants, to parenting outcomes including stress, knowledge, and attitudes.

Introduction: Research on Home Visiting Service Delivery

While research focused on the nature and content of home visiting remains sparse, a recent meta-analysis found that effect sizes for numerous program outcomes varied depending on program structure and approach (Filene 2012 ; Filene et al. 2013 ). Specifically, program-related variables such as having professional vs. nonprofessional home visitors, matching home visitors and women based on race/ethnicity, and relative emphasis on various topics such as parenting and responsiveness were associated with positive effects on some outcomes (Filene 2012 ; Filene et al. 2013 ). Utilizing descriptions of program models and curricula, the authors found larger effects in parenting-related outcomes for programs that emphasized information about developmental expectations and specific behavior management skills. One study that collected data specific to visit content reported that the larger the percentage of time home visitors spent on child-focused activities, the greater positive outcomes were found for child cognitive and language development, parenting, and maternal depression (Raikes et al. 2006 ).

Meta-analytic strategies to summarize home visiting outcome literature looking at service variability, including dosage predictors, point to increases in number of total hours in home visits, and home visit ‘frequency/intensity’ to be related to stronger program effects (Sweet and Appelbaum 2004 ; Nievar et al. 2010 ). Research examining how home visiting dosage and content influence outcomes is complicated both in terms of how different researchers operationalize “dosage” and by the interaction between level of family risk and service delivery. Research contends that as the number of risk factors accumulate for women and families, so does the potential for negative maternal and child outcomes (Burchinal et al. 2008 ; Trentacosta et al. 2008 ; Cabrera et al. 2011 ). At the same time, families at highest risk for negative outcomes and who may be most in need of services, may be challenging to both enroll and retain in services (Gomby et al. 1999 ; Howard and Brooks-Gunn 2009 ).

To address these gaps, the following exploratory research questions were developed:

• What content areas comprise the time spent in MIECHV-funded home visits?
• Do women who receive more home visits report greater improvement in parenting attitudes, knowledge, or parenting stress?
• Do women whose visits are characterized by a greater emphasis on parenting content show more improvement in parenting-related outcomes?
• Does the influence of number of home visits on outcomes differ for families at higher-risk for negative family outcomes compared to those at lower-risk?

Research was conducted in accordance with ethical principles and guidelines, and reviewed and approved by the Oregon Health Authority, Public Health Division, Institutional Review Board.

Study Recruitment

Study participants were newly enrolled or within 6 visits in MIECHV funded home visiting services in 13 counties in Oregon. Women were 16 years of age or older, spoke either English or Spanish, and either pregnant or parenting a child < 12 months of age. Home visitors asked interested women for their consent to be contacted by the research team, who then sent study information and the baseline survey via either mail or email. Participants also provided consent for their home visitor to provide the research team with regular information about their visits. For clarity, the terms women and participants will refer to those who consented to be in the study.

Data Collection

Participating women completed surveys at study enrollment (baseline) and again 12 months later. Women received a $25 gift card incentive to a local store for completing the Time 1 survey and a $40 gift card at Time 2. Research staff contacted participants monthly between Time 1 and Time 2 to confirm their contact information and support study retention. In all, 132 out of 197 women who expressed initial interest in participating in the study completed a Time 1 survey (67%) and were included in the study. We do not have systematic data on those who chose not to complete the baseline survey, however, some were not eligible due to recruitment window parameters or stated exclusion criteria. Of the 132 Time 1 respondents, 123 (94%) returned a Time 2 survey. Forty-five home visitors working with women provided weekly logs detailing home visiting content. Approximately 90% of expected weekly logs were submitted, with an average of 32.6 logs per family (range 1–60).

Measures: Participant Surveys

Baseline surveys included demographic, and individual and family risk information. Risk factors were identified based on known correlates of negative parenting behaviors, harsh punishment, or extreme parenting stress, selecting brief, validated screening tools whenever possible. In some cases, we worked with state home visiting partners to shorten existing measures to reduce burden to participants. Indicators of psychosocial risk level were: Low social support (the number of people women could turn to for support); Presence of family relationship problems (“none or minor”, “some”, or “serious”); Depression risk (PHQ-9; Kroenke et al. 2001 ); Presence of interpersonal family violence (Pregnancy Risk Assessment Monitoring System-Phase 6; Centers for Disease Control and Prevention 2009 ); Maternal substance use (3-item version of the Simple Screening Instrument for Substance Abuse (SSI-SA); Knight et al. 2000 ); and history of adverse experiences (4-item version of the Adverse Childhood Experiences Questionnaire; Centers for Disease Control and Prevention 2014 ).

The items on the SSI-SA included three questions asking about drug use and problems related to drugs or alcohol in the past 6 months, and a fourth question about having a current drinking or drug problem. For adverse experiences growing up, respondents indicated if they had ever been in foster care, or if anyone in their family had a problem with drugs or alcohol abuse, depression or mental health issues, or incarceration. We chose not to ask questions about participants’ experience of maltreatment within their family of origin (a known risk factor for negative parenting), given the intrusiveness of these questions in terms of potential for retraumatization and lack of face-to-face support during survey administration. Each indicator was dichotomized to indicate the presence of the risk factor (1 = yes, 0 = no).

Cumulative Risk Factor Index

A cumulative risk factor index was calculated using the sum of 12 dichotomized risk variables including: becoming a mother at 19 or younger, premature birth of their child, less than a high school education, housing instability, household unemployment, single relationship status, low social support, troubled relationships, depression, interpersonal violence, drug problems, and adverse childhood experiences. The substance abuse problem items were dichotomized such that if a mother indicated a positive response to any items (e.g., had used too much, tried to cut down, or felt like she had a drug problem), it was coded as the presence of the drug problems risk factor.

Outcome Measures

Parenting outcomes were collected at Time 1 and Time 2. Parenting knowledge was assessed with the UpStart Parent Survey (USPS) Parenting Knowledge/Skills subscale (Benzies et al. 2013 ). Parenting attitudes were assessed using Corporal Punishment and Empathy subscales from the Adult Adolescent Parenting Inventory (AAPI-2; Bavolek and Keene 2001 ). We also used two of three subscales of the Parenting Stress Index-Short Form (PSI-SF), the Parenting Distress (PD) and Parent–Child Dysfunctional Interaction (P-CDI) subscales (Abidin 1995 ; Haskett et al. 2006 ), to measure stress related to the parenting role. See Table  1 for example items for measures and reliability data.

Parenting outcomes: example of items on measures

Number of Home Visits

Given the variability in the timeframes when home visit logs were collected, we used home visit data housed in the MIECHV Oregon administrative database for home visit total dosage. The program dosage outcome was calculated as the total number of visits received by participants between their enrollment date and the date they completed the Time 2 survey. We also used this strategy due to concerns that the amount of time spent in home visits may have reflected program requirements rather than actual time spent.

Home Visit Content

The content log was developed based on a thorough examination of the literature, review of existing tools (Home Visit Rating Scales; Boller et al. 2009 ), and in consultation with home visiting research experts and stakeholders. We also incorporated home visiting service areas from the Mother and Infant Home Visiting Program Evaluation study (U.S. Department of Health and Human Services Administration for Children and Families Office of Planning, Research and Evaluation 2015 ). Content areas were refined based on feedback from home visiting model leads and home visitors about typical visit topics and seemed to have good validity; however, we did not systematically validate this measure. Home visitors accessed an on-line log system to document the estimated time spent during visits in ten specific content areas (see Table  2 ). Incremental time spent response categories were developed due to the reported difficulty of home visiting staff, and potential inaccuracy, of estimating actual time spent. Response choices for content areas included “did not discuss”, “touched on briefly”, “discussed 10–15 min” and “discussed more than 10–15 min”. Logs were to be completed after each home visit and submitted electronically to the research team, including reporting when no visit occurred for the week.

Home visiting content areas and activity log examples

TANF temporary aid to needy families, SNAP supplemental nutrition assistance program, OHP Oregon health plan

Because there were more actual visits documented in the MIECHV database when compared to number of logs received, we elected to create an overall estimate of time spent on each area across all logs received for a family. First, study content data were collapsed into the four overall topics or domains with similar conceptual focus: self-care, parenting, life course, and support networks/referrals. This average rating was then multiplied by the number of home visits (from MIECHV database) the family received to generate the estimated “ content dosage ”. Thus, the content dosage variable does not reflect actual time estimates, but provides a proportional representation of the amount of time on a given domain across all visits. For example, two families with a similar average amount of time spent on self-care across home visits, but who had different quantities of home visits, would have different “content dosage” scores for self-care.

Multivariate regression models were tested using Time 2 outcome scores for each of the primary parenting outcomes (UpStart, AAPI, and PSI), controlling for scores at Time 1. All models included the following covariates: white/non-white, completed high school (yes/no), marital status, number of adverse childhood experiences (ACEs), and depression risk. To examine whether home visit dosage had differential effects on outcomes for women with higher-risk versus lower-risk profiles, we used the cumulative risk score to calculate multiplicative interaction terms (e.g., number of visits × cumulative risk score) and included terms in the models as predictors. For models testing interaction effects, demographic characteristics included in the cumulative risk score were not included as covariates.

Study Sample and Descriptive Data

Table  3 provides demographic characteristics for women in the study. Slightly more than half of the women reported White race, while 21% reported Hispanic/Latina race/ethnicity.

Selected study participant demographic characteristics

a 20% were categorized as ‘other’; 0% Asian

Women had an average of 3.4 of a possible 12 risk factors (range 0–8 of possible 12; SD 1.98). Sixty-one percent of women had between 1 and 4 risk factors, and 26% of women reported between 5 and 8. Only 7% of women had zero risk factors. Descriptive information on parenting outcome scores is presented in Table  4 for both the baseline and 12 month surveys.

Parenting outcome scores at Time 1 (baseline) and Time 2 (follow-up)

Table  5 presents descriptive information on the time spent in specific home visiting content areas as reported by home visitors on weekly logs. Home visit logs indicated a stronger focus on providing parenting information, with more than half of reported visits spending “at least 10–15 min” on early childhood development, physical care of children, or the parent–child-relationship. On average, the least time was spent on information and family resource referrals, with about a quarter of visits not covering resources at all, and 61% covering the domain only briefly. Considerable visit time was devoted to maternal self-care, especially maternal emotional health, with 45.7% of visits spending at least 10–15 min on the mental health of the mother.

Average time spent in content area reported by home visitors on weekly logs

Table  6 details program dosage based on number of home visits, as well as the average content dosage in four domains. The data indicate considerable variability in the number of home visits families received, ranging from 1 to 56 visits (mean 28 visits; SD 14.9). Visits were approximately one hour, on average (mean 67.46 min; SD 11.4; range 40–98). Proportionately, a greater amount of time in visits was spent on the parenting content domain compared to the self-care, life course, or support network/referrals content domains.

Time spent in home visiting (dosage) and content dosage (four domains)

a Estimated dosage is calculated by weighting the average amount of time spent per content domain by the number of home visits received by the family

Association of Dosage and Content Dosage to Parenting Outcomes

Separate regression models were tested for each of the three parenting outcomes, with predictors modeled separately for each. Predictors included dosage (number of visits), and content dosage in self-care, parenting, life course, and support network/referrals. All models included the covariates described previously. Results of regression models are shown in Table  7 .

Regression model results—association of home visiting estimated content dosage to Time 2 outcomes, controlling for Time 1 status

Regression coefficients represent the effect of each of five dosage predictors [number of visits received (1) and type of home visit content (2–5)] on Time 2 outcomes controlling for Time 1 outcomes and for the following covariates: white/non-white, high school education, married/partnered, total depression score (PHQ scale), total number of adverse childhood experiences

† p ≤ .10; *p < .05; **p < .01

Parenting content dosage was significantly associated with decreased parenting stress at Time 2. We identified a trend toward significance, indicating an association in which other content areas predicted parenting stress as well, although the number of visits alone was not related to decreased stress. Figure  1 displays the association between parenting content dosage and parenting stress, categorizing parents as receiving “high” versus “low” parenting content dosage (using a median split for high/low). Neither the number of visits nor the four content dosage areas were associated with changes in parenting attitudes (AAPI) or parenting knowledge (UpStart).

Higher parenting related content dosage is related to lower parenting stress at Time 2 for home visited families

Association of Family Risk Factors and Home Visit Dosage to Parenting Outcomes

The final research question explored whether the effects of dosage on outcomes differed for families with varying risk levels. Regression models used the Time 2 parenting outcomes and demographic covariates as noted above, and also included the following predictors: outcome scores at Time 1, cumulative risk factor index score, home visit dosage (number of home visits), and the cumulative Risk Factor Index × Home Visit Dosage interaction (Table  8 ). A significant main effect of risk was found, such that those families with more risk factors were more likely to endorse the use of corporal punishment. The interaction, Risk Factor Index × Home Visit Dosage, was also significant (Fig.  2 ). The interaction suggests that attitudes towards corporal punishment (i.e., indicating less positive attitudes towards corporal punishment with lower scores at T2) improved more for families who were higher-risk but also received a greater number of home visits compared to higher-risk families who received a low number of visits. In post hoc tests looking at the differences between the T1 and T2 scores of the AAPI, for the Corporal Punishment subscale, only the high-risk, high dosage participants showed a significant change (reduction in endorsement of harsh parenting practices). In this instance, the AAPI Empathy subscale was not a key driver in explaining results.

Regression models testing moderating effect of risk factor index (# of risks) × dosage (# of home visits) on parenting outcome effects

Cumulative risk moderates the impact of dosage (# of home visits) on attitudes toward corporal punishment for home visited families

The current study focused on the relative emphasis on a variety of topics across the span of home visits received by families for up to 1 year. While visit content varies considerably, we found a relatively greater emphasis on parenting-related content areas. In particular, home visits were most likely to focus on information related to the physical health of the child, child development, and support for the parent–child relationship, all critically important during the child’s earliest years of life. The prominence on parenting and child development-related topics is not surprising, given the emphasis of the three home visiting models studied, all of which aim to improve parenting skills and support strong parent–child relationships. Also worth noting is the finding that home visitors dedicated a substantial amount of time, on average, to helping women take care of their own physical and emotional health, maternal self-care, and supporting family stability and adult life goals as compared to other areas. Relative to content related to life goals, resource referrals, and broader network supports, women spent more time talking with home visitors about their own emotional health. The focus on women’s mental health needs may reflect the growing awareness in the home visiting field of issues related to maternal depression, and the need to provide trauma-informed services to women who may have experienced one or many adverse life experiences. Within MIECHV programs, depression screening and referral is a required element of services, and working with women with depressive symptomatology has been an area of increased professional development and supervisory support.

Women and families who received greater numbers of visits with relatively more parenting content had significantly greater reductions in parenting stress from baseline to follow-up, although the magnitude of effects was modest. Focus on other content areas was also associated with reductions in parenting stress, although effects only approached significance. Reduction in parenting stress is one of the central goals of home visiting programs. Focusing on parenting skills and building parents’ confidence is an important pathway to helping new parents feel less stress as they acclimate to their growing family.

Additionally, our study suggests that for higher-risk families, receiving more home visits may be particularly important to supporting changes in parenting-related attitudes. Families who had greater numbers of risk factors and who also had a greater number of home visits were less likely to endorse the use of corporal punishment compared to high-risk families with fewer home visits. The number of visits received was not associated with changes in parenting attitudes among lower-risk parents. That said, successfully engaging higher-risk families may be particularly important, and they may experience greater benefit from visits than lower-risk families. At the same time, results underscore the importance of providing a sufficient number of home visits in order to achieve desired changes in parenting and other outcomes, a feature of home visiting that has long been recognized but can be challenging to achieve (Gomby et al. 1999 ; Howard and Brooks-Gunn 2009 ). Programs would also do well to consistently screen, identify, and enroll families dealing with multiple stressors, and work on creative strategies and schedules to provide visits often and regularly for these women. Given the realities of living with numerous life challenges and the potential difficulties in complying with a “regular” schedule of home visits, designing early engagement strategies that build relationships and trust with families, and providing flexible visit structure options may help increase success in reaching these families.

Limitations and Future Research

These findings should be considered within the context of the limitations of the study, and within the broader context of study results for home visiting programs nationally. First, generalizability of our findings to all women in home visiting programs is not possible, as the sample included only those who completed surveys after indicating initial interest. It is possible that those who were not included are systematically different in some (unmeasured) ways from those included in the final sample, for example, if the most vulnerable families chose not to participate. Second, the measure of home visiting content, while instructive, included the home visitors’ subjective estimates of the relative emphasis of different topics covered with women and families. Future research is needed to validate this approach, including objective observations of visits and concurrent parent report of visit content.

Further, data collection started later than originally planned which created gaps in home visit logs during the first 90 days of enrollment. As a result, we did not have complete information about content for all visits. Instead, we developed estimates of the average time spent in each content area. This approach is inherently limited, as it assumes that home visitors provide roughly the same type of content evenly across home visits from enrollment to family exit. It is possible, however, even likely, that greater amounts of time are spent in early visits on some topics relative to others, a dynamic that could not be reflected in our data. More precise measures of visit content might include tablet-based recording of activity immediately during or after visits or coding based on videotaped visits. Additional research to understand how content changes over time (e.g., greater information/referrals at early visits) would be informative as to whether the type of content provided early versus later facilitates (or impedes) a family’s willingness to engage in continued services.

The delays in start-up may also have reduced the study’s ability to detect changes over time in parenting outcomes. First, some Time 1 parent surveys were sent later than planned, an average of 120 days after a family’s initial enrollment in home visiting, possibly leading to elevated baseline scores. Second, sample sizes in the current study precluded potentially meaningful subgroup analysis (e.g., comparing differences in visit content or outcomes for families with different baseline characteristics). Future research should strive to follow families for a longer period of time. The original design called for 12 months between baseline and follow-up to maximize exposure to program content. However, about half of the sample were enrolled for less than 6 months at the follow-up time point, a short period to be able to reveal meaningful outcome changes. To better explore the relationship of visit and content dosage over time as they relate to positive parenting outcomes, future studies should ideally follow families from enrollment to program completion (up to 3 years in some MIECHV-funded programs).

An important area for future research suggested by these findings includes exploring the relationship of women’s trauma histories to both visit content and outcomes of home visiting. Women are routinely asked to report about multiple areas of interpersonal struggle (e.g., ACEs, depression, intimate partner violence). Looking closely at how programs and visitors may or may not “flex” to accommodate client needs around disclosure of trauma is key. Providing trauma-informed practices implies that those women who disclose significant adverse life events or mental health challenges may benefit from spending more time during visits discussing emotional and mental health issues. Does spending more time in self-care/emotional health content during visits link to improvements in parent mental health functioning or positive parenting practices? Are specific programs or types of visitors better suited to support these women and families? Given the growing awareness of the extent of past trauma and existing struggles for many of the women receiving home visiting services, better understanding of how program content and visit schedules can be tailored to best meet parent needs is a priority for future research.

Acknowledgements

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Affordable Care Act—Maternal, Infant and Early Childhood Home Visiting Program Expansion Grant, Grant number D89MC26363. The authors thank Eleanor Gil-Kashiwabara, Paul Sorenson, Amy Gordon, and Camilla Pettle for logistics and technical support. We are grateful to the Oregon Health Authority, Public Health Division, Maternal and Child Health staff for their guidance and strong partnership. We also thank the home visiting staff, and women and families who participated in this research for their generosity of time and insights.

Compliance with Ethical Standards

Conflict of interest.

The authors declare no conflicts of interest.

The original version of this article was revised due to a retrospective Open Access order.

The information and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Change history

The article “What’s Happening During Home Visits? Exploring the Relationship of Home Visiting Content and Dosage to Parenting Outcomes”, written by Peggy Nygren, Beth Green, Katie Winters and Anna Rockhill, was originally published electronically on the publisher’s internet portal (currently SpringerLink) on 13 June 2018 without open access.

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Coding for E/M home visits changed this year. Here’s what you need to know

CPT has revised codes for at-home evaluation and management (E/M) services as of Jan. 1, 2023. Services to patients in a private residence (e.g., house or apartment) or temporary lodgings (e.g., hotel or shelter) are now combined with services in facilities where only minimal health care is provided (e.g., independent or assisted living) in these code families:

Home or residence E/M services, new patient

• 99341, straightforward medical decision making (MDM) or at least 15 minutes total time,

• 99342, low level MDM or at least 30 minutes total time,

• 99344 (code 99343 has been deleted), moderate level MDM or at least 60 minutes total time, 

• 99345, high level MDM or at least 75 minutes total time.

Home or residence services, established patient   

• 99347, straightforward MDM or at least 20 minutes total time,

• 99348, low level MDM or at least 30 minutes total time,

• 99349, moderate level MDM or at least 40 minutes total time,

• 99350, high level MDM or at least 60 minutes total time. 

Select these codes based on either your level of medical decision making or total time on the date of the encounter , similar to selecting codes for office visits . The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in those settings.

When total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. The exception to this is for patients with Medicare. For those patients, report prolonged home or residence services to Medicare with code G0318 in addition to 99345 (requires total time ≥140 minutes) or 99350 (requires total time ≥110 minutes). Code G0318 is not limited to time on the date of the encounter, but includes any work within three days prior to the service or within seven days after.

Services provided in facilities where significant medical or psychiatric care is available (e.g., nursing facility, intermediate care facility for persons with intellectual disabilities, or psychiatric residential treatment facility) are reported with codes 99304-99310 .

— Cindy Hughes, CPC, CFPC

Posted on Jan. 19, 2023

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Home Visitor Safety

You can work with other program administrators and community resources to implement policies, procedures, and strategies that can contribute to home visitors’ and families’ safety in unsafe situations. As you put safety plans and measures in place, keep the following concepts in mind [ 5 ]:

Sometimes situations, such as crises, arise that pose some degree of risk to the safety of family members and home visitors.  The potential for physical harm exists in any emotionally charged crisis. Staff should never overlook or discount that potential.

Home visitors’ skills in handling a potentially dangerous situation shape intervention decisions. Sometimes home visitors find themselves faced with, or caught up in, a family situation that is too complex or too dangerous for them to address directly. At such times, it is critical to recognize that the situation is beyond their intervention abilities and to discuss alternatives with their supervisor.

The best predictor of impending danger is behavior. Safety measures are called for if a family member's current or past behavior includes violent/abusive acts, threats of harm, criminal activities, the use of addictive substances, signs of a serious emotional disorder, or threats of suicide. These measures are needed at several points in the intervention process: before face-to-face visits with the family, during face-to-face visits, and as part of referral and follow-up services.

Home visitors must always be aware of behaviors and situations that signal danger. Some violent incidents may be predicted, but many helping professionals fail to recognize signs of potential violence. Signs of loss of control and impending danger include expressions of anger and hostility. Staff may also sense that a situation is dangerous; know the family has access to guns or other weapons; be aware of violent acts or threats by family friends or relatives; and recognize mounting tension, irritability, agitation, brooding, and/or limit testing in family members.

Home visitors must be and feel safe if they are to support families. Home visitor safety can and must be addressed at many levels. The threat of violence does not occur only in the homes of families or in high-crime neighborhoods, but also in seemingly secure workplaces. Work conditions favorable to violence prevention require action at management, supervisory, and personal levels.

Some general strategies that you may consider include the following:

• Have home visitors work in pairs, particularly when they go to more dangerous neighborhoods. Accompany home visitors, if needed.
• Forge a relationship with the local police department. When police are aware of home visitors’ presence in the community, they may be able to provide protection such as self-defense training and alerts as to potentially hazardous events in the community.
• Provide cell phones, beepers, or other communication devices. Work with finance and other program staff to ensure the budget covers this equipment.
• Involve families in home visitor safety. They often know of potential safety hazards in the neighborhood (e.g., high-crime areas, gang activity) and can inform home visitors of the safest way to travel through the area.
• Work with program administrators and community resources to develop crisis protocols and make sure home visitors are aware of them. Provide opportunities for home visitors to review and practice implementing protocols. Topics may include child abuse/child neglect, substance misuse, violence in the neighborhood, and the presence of a contagious disease.
• Make sure that you or another administrator is “on call” whenever a home visitor is in the field, including after hours and weekends, so that home visitors can get an immediate response when needed.
• Make sure you know home visitors’ schedules. This should include family names and contact information, date and time of visit, and when to expect the home visitor to return. 

In addition, you might encourage home visitors to do the following [ 4 ]:

• Trust their instincts. If they feel something is not right or see something in the home that makes them uncomfortable (e.g., physical or verbal violence, alcohol/drug use, evidence of firearms, or the presence of an acutely intoxicated individual), follow established protocols and leave, if necessary. Encourage home visitors to say to the parent, “Maybe this isn’t a good time for a visit. Let’s reschedule.” Before going on future visits, encourage home visitors to talk with you about how to ensure their safety in the home. Work with home visitors to talk with the parent about the issues that made them feel uncomfortable and to make referrals if needed.
• Wear comfortable shoes.
• Get clear directions to the neighborhood and the home or apartment building, especially for new visits. Take a practice drive to make sure the directions work. Confirm how to enter the home if it is a duplex or apartment.
• Ask families where it is best to park, and park as close to the home as possible. Always park in well-lit areas. If it is not possible for the home visitor to park in a safe place, discuss other options, such as meeting the family in another setting or being driven and picked up by a co-worker.
• Put any important or valuable items in the trunk of the car before arriving for the visit. Avoid carrying and wearing expensive items.
• Contact parents before a visit so they can be on the lookout for the home visitor.
• If no one answers the door, sit in the car or drive around the block rather than wait at the door. Make sure to specify the amount of time home visitors should wait if a family is not home as part of your home visit protocol.
• Make sure home visitors’ cars are in good working order and that there is plenty of gas in the tank.
• Organize belongings so they do not have to take time to search for them. For example, when they leave a home visit, they should have their keys in hand.

4 Rebecca Parlakian and Nancy Seibel, Help Me Grow Home Visitor Curriculum (Cuyahoga County, OH: Help Me Grow of Cuyahoga County, 2005).

5 Head Start Bureau, “Assessing Family Crisis.” Excerpts from Training Guides for the Head Start Learning Community: Supporting Families in Crisis (Washington, DC: Department of Health and Human Services, Administration for Children and Families, Administration for Children, Youth and Families, 2000), https://eclkc.ohs.acf.hhs.gov/mental-health/article/assessing-family-crisis.

Resource Type: Article

National Centers: Early Childhood Development, Teaching and Learning

Program Option: Home-Based Option

Last Updated: May 22, 2023

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