Waves of Change in Home Visiting: Transforming Practice, Maximizing Impacts

1. Waves of Change in Home Visiting:Transforming Practice, Maximizing Impacts Deborah Daro

2. Interest in home visiting is the logical consequences of 40 years of investing in early childhood to maximize our human capital. The AIA grantees offer the EBHV home visiting field important learning opportunities for extending the impacts of state and Federal investments in the model. The AIA and MIECHV efforts face similar challenges in Developing a competent and effective work force Replicating programs with fidelity while creating innovation Building integrated systems of care Main Points

3. The Evolution of Home Visiting

4. Wave 1: Gradual recognition of home visiting as a unique and powerful service strategy. Wave 2: Extensive testing and replication of multiple national home visiting models. Wave 3: Achieving national recognition and securing Federal investment. Wave 4: Successfully using home visiting as leverage to secure sustainable change. Past and Potential Future of Home Visiting

5. Promising Characteristics of Home Visiting • Provide services in a participant’s home, reducing the barriers to engagement. • Allows one to target and shape the intervention to the needs of each specific family. • Facilitates contact with other family members and care providers. • Models “relationship building”.

6. Convergence of political interests, clinical knowledge and empirical research. Success of home visitation efforts in achieving positive outcomes – there is evidence the strategy works. Hawaii’s statewide expansion of Healthy Start – there is evidence you can do this to scale. Offered promise of greater reach. Factors Supporting Home Visiting Expansion

7. Initiated During Pregnancy/Birth Better birth outcomes (if offered during pregnancy) Enhanced parent-child interactions Positive maternal life and health choices More efficient use of health care and community services Enhanced child development and early detection of developmental delays Toddlers Early literacy skills Social competence Parent involvement in learning Documented Outcomes of Home Visiting

8. National HV models grew rapidly between 1990 – 2010 -- serving 400,000 to 500,000 families. Specific State-level investment 40 states provided a total of 70 different home visitation models to local residents. 34 states engaged in interagency planning around the model and 15 states have established tiered systems to serve high and low risk parents. Total expenditures in these models exceed $250 million by 2010. Initial State Investments in Home Visiting

9. Maternal, Infant, Early Childhood Home Visiting • Goal • Included in the 2010 Affordable Care Act • Assists states in building a comprehensive early childhood system to promote the health and safety of pregnant women, children 0-8 and their families • Investments • $1.5 billion allocated to states FY 10 to FY14 on a formula and competitive basis • $11.2 million for Technical Assistance • $27 million for a national evaluation, focused primarily on documenting participant outcomes

10. MIECHV Opportunities • Creates a structure for interagency collaboration and a new type of public-private partnership. • Promotes higher quality practice across all agencies and interventions. • Promotes resource and coalition building at the community level. • Raises the national profile of the importance of a child’s first five years of life.

11. MIECHV Challenges • Insufficient resources to achieve the initiative’s immediate and aspirational objectives. • Cumbersome regulations and significant data demands on all stakeholders. • A time frame that fails to account for the slow pace of change and complex local regulations. • The lack of a coherent decision making framework to manage all diverse interests.

12. AIA’s Key Contributions to Field Building • Knowledge on how to identify and engage important high risk populations. • Knowledge on how to integrate mental health services within the context of home based interventions. • Strategies to create effective policy and practice linkages with child welfare, substance abuse, and justice systems.

13. How to train and empower the home visiting workforce to bring added value and innovation to program development. How to balance the equally important tasks of replicating with fidelity and developing innovations. How to capture the concept of “collective impact” in building effective service partnerships. Shared Opportunities for Learning

14. Elevating Workforce Quality and Consistency

15. Why are the best programs working? • Theoretical integrity and focused content. • Focusing intervention efforts on the earliest stages of the developmental process. • Employing persistent, but respectful, outreach methods to engage multi-problem families. • Systematically assessing the needs of the target population across a number of domains that impact relevant risk and protective factors. • Providing participants access to a core body of knowledge and skills and facilitating access to other community resources as needed.

16. Key Elements for an Effective Work Force • The ability to bring added value to any task. • Identify opportunities to enhance the service experience. • Balance the need for fidelity with the potential for innovation. • A robust knowledge base in key areas and a “curiosity” to learn more. • A skilled “relationship builder” who connects with both program participants and colleagues. • A commitment to cultural humility. • Move from mastering a body of knowledge to sustaining an ongoing commitment to learning and understanding.

17. Strategies To Strengthen Workforce Capacity • Self-generating peer learning opportunities across home visitors, supervisors and agency managers. • State/county training centers • To support initial model implementation • To provide ongoing staff development opportunities • To support core competencies and service components. • Annual state meetings/conferences for all home visiting program providers and others serving young children and their families.

18. Balancing Fidelity And Creating Innovation

19. The Dilemma • Maximizing population level change requires that promising interventions and policies be taken to scale with fidelity. • Extending a program’s “reach” often requires adaptation and modification to meet the needs of emerging populations and changing conditions. • Such adjustments, if not carefully done, can and does reduce a program’s impacts.

20. Lack of internal organizational capacity Lack of guidelines regarding innovation or model adaptation “Gravitational pull” Common Barriers to Quality Expansion

21. Careful selection of replication sites. Clear implementation guidelines and compliance indicators. Strong initial training, ongoing coaching and a process for early monitoring of key practice principles. Time sensitive management information systems and feedback on participant outcomes. Factors Facilitating Quality Replication

22. Quality Program Improvement Cycle

23. An Integrated Vision: Elevate the Mission and Plan for Systemic Change

24. Integrated Data Systems/ Common Measures Shared Activities And Functions Common Vision/Shared Outcomes Multi-Agency Collaborative Chapin Hall

25. Building “Collective Impact” • Establish a common agenda that moves the mission outside any specific agency “silo”. • Obtain agreement among partners on: • Time horizon – when do you want to see change. • Risk – tolerance for innovation and new practice. • Scope – size of the target population/geographic area. • Agree on a shared definition of “success” • Establish benchmarks and develop a system to monitor progress toward objectives across all investments. • Use data to understand the present and plan for the future. Kania & Kramer, 2011. Collective impact. Stanford Social Innovation Review, (Winter), 36-41.

26. Building “Collective Impact” • Identify mutually reinforcing activities (positive “spill-over” effects) • Determine appropriate balance between infrastructure and programmatic investments • Encourage ownership of a new idea or reform through active participation in decision making • Understand the value in collective action and shared resources and act in ways that build interdependence • Foster continuous communication and feedback loops • Create a new, independent “backbone” organization or service program to link elements together Kania & Kramer, 2011. Collective impact. Stanford Social Innovation Review, (Winter), 36-41.

27. Set benchmarks for direct services at the population level not simply for those receiving services Improving child and maternal health Preventing injury, maltreatment and violence Improve school readiness Improve family self-sufficiency Establish specific benchmarks to track system change Document efficiencies in agency operations Document interagency activities Track shifts in the source and level of all investments Redefining The Benchmarks for Success

28. The Great Society asks not how much, but how good; not only how to create wealth but how to use it; not only how fast we are going, but where we are headed. It proposes as the first test for a nation: the quality of its people. This kind of society will not flower spontaneously from swelling riches and surging power. It will not be the gift of government or the creation of presidents. It will require of every American, for many generations, both faith in the destination and the fortitude to make the journey. And like freedom itself, it will always be challenge and not fulfillment. LBJ (1965) Staying the Course