bill set you up running this is a committee has a proud tradition of working on a bipartisan basis to ensure the safety and well being of children and i hope today marks the beginning of our next step toward that  goal last year we produced major legislation to help relatives caring for foster children to provide support for tens of thousands of children who are now age out of foster care on their eighteenth birthday and to improve the oversight of health  and educational needs of children and to increase the support for adoption assistance but when we pass that bill i said at the time our job is far from done we still have a child protection system that is designed primarily as a response program rather than a prevention and response program along with danny davis and todd platts i put forward legislation last week to take a more proactive approach to helping families the early support for families act h r twenty six sixty seven would provide federal funding for home visitation programs to reduce child maltreatment as well as to improve children's health and school readiness as the federal department of health and human services declared under president bush quote there is a growing body of evidence that some home visitation programs can be  successful as a child maltreatment prevention strategy i agree and i think we ought to proceed down that road the early support for families act follows president obama's budget recommendation to provide grants to states to help them establish or expand their voluntary home visitation programs for families with young children and families expecting children only programs using evidence based models that have demonstrated positive effects on important child and parenting called comes should be eligible for the funding home visits could start during pregnancy and could be conducted by nurses or social workers or trained paraprofessionals the visits would focus on providing information on child health development and care on parental training and support and on referrals to other services many states have whole visitation programs funded with state dollars and or  of federal funding according to the pew center on states less than fifteen percent of families needing a home visitation are now sir the legislation we put forward would provide a dedicated funding source to authored a home visitation bill in the education and labor committee during the last congress and the principles of that legislation were really a guiding force in the bill that we put forward together i don't believe home visitation would be so squarely on our agenda without his efforts i also want to add that there is some talk about adding this provision to the health care reform bill that is presently being  through the congress whether or not that happens or not remains to be seen but i would now like to recognize my ranking member mr landor thank you mr chairman today's hearing offers a timely reminder of the differences between the fantasy land of washington d c and the reality of the rest of america here in fantasy land we'll discuss adding one more multibillion dollar entitlement program this would be on top of the new higher education the taliban program created this year and of course our current health care and last week that in two thousand and eight the average u s household loaded almost five hundred fifty thousand dollars in federal debt that's four times what the same average household ozen mortgage car loans credit card and other debt combined and that's before this year's trillion dollar or geo so called stimulus spending meanwhile in the real world the recession is forcing states to cut current spending in california the governor proposes eliminating the welfare to work program and health insurance for nearly one mil low income kids after their two thousand and nine budgets passed forty two states and acted emergency spending cuts totaling thirty two billion dollars these are not minor adjustments that the legislation we will discuss today breez assumes the states will find three billion dollars in new money over the next decade to finance their part of this new entitlement where all that money come from the tooth fairy being a dentist i can tell you something about that but i won't say it out loud i don't often agree with robert greenstein the head of the liberal center on budget and policy priorities last week and there were times he said a budget tsunami is coming that's right you'd be taken a hell of a lot more seriously our witnesses will discuss how some home visitation programs are shown some positive effects we know that from programs already operating often with federal and state program money but obviously our colleagues think it is not enough because it i never enough if you add up all the federal and state funds states could spend on home visitation it is an incredible two hundred forty four billion dollars a year obviously states don't spend all that money th way having other priorities or nominating to cut other priorities so we in washington will create a new program forces them to a program that increases child abuse prevention funds that may be spent on home visitation but a program  way or the highway except the children will be the ones who will really pay when the coming budget tsunami washes this and so many other programs away chairman all of us are interested in making sure every child gets a good start in life i support reviewing reviewing current home visitation programs that fall under the committee's jurisdiction and how they can be improved however at this time of massive and growing federal and state deficits i simply cannot support the creation of a new entitlement that would send another eight have million dollars in unpaid for federal spending out the door to help illustrate the current economic situation and closing i ask unanimous consent to insert three documents in the record at this point first is associated press article from last week that lists the massive spending cuts under consideration in california today to bring its budget into balance the second as wall street journal article from last week title states but you always are poised to worsen and the third is the latest summary of the federal budget situation by the congressional budget office showing that the federal deficit was one hundred eighty billion dollars just in the month of may thank you mr chairman without objection those articles will be entered into the record thank you john the first witness will be joan sharpe who is the executive director of the council for children families of washington my home state one committee my name is joan sharpe i am the executive director of the council for children and families in washington state we are a small state agency an office of governor we also serve as the children's trust fund of washington and the washington chapter of prevent child abuse america our mission is to prevent child abuse and neglect before it occurs we strongly support this committee's efforts to advance home visiting legislation i'm here today to share with you our experience and expertise in funding monitoring and supporting evidence based holmes's station programs from our twenty seven years of leading child abuse and neglect prevention in washington state this is what we have come to know with great certainty child abuse and neglect are preventable to ensure a better future for washington's children we work to increase public understanding of child abuse in order to engage individuals families communities and systems in becoming part of the solution in the last five years we have increasingly focused on evidence based home visiting as our preferred strategy to decrease child maltreatment in two thousand and six the council for children and families proposed to the washington state legislature a substantial expansion of evidence based home visiting programs this request followed a period of significant preparation first we had quantified the need our research the justed that fifty percent of families under one hundred eighty five percent of poverty of  federal poverty level with children birth to five or a total of about twenty five thousand families annually in washington would be eligible for or appropriate for and would voluntarily participate in the home visiting program we also convened a research advisory committee of academics academicians providers and other inform stakeholders to set the criteria that we would use to establish a reasonable yet rigorous eviden threshold we were then able to identify a number of home visiting models that met these criteria in addition we conducted statewide outreach we wanted to ensure that communities understood evidence based programs before they embarked on their own process to determine local interest resource availability and which model might best meet community needs and conditions in two thousand and seven the washington state legislature appropriated three point five million dollars over a two year period to fund evidence based on visiting we then implemented a request for proposal process identified the strongest applicant serving high need communities and initiated performance based contracts to implement an array of evidence based on visiting programs serving diverse communities across the state we are since begin to be to see the very positive outcomes that these programs are developing with washington's what vulnerable children and families we're also seeing that is the strong benefit of these programs is to be wide felt stored in those local resources alone will not get us to our goal the council for children and families supports in a range of evidence based home visiting models well we want for our children and families only the strongest programs the truth is that with limited research dollars available many promising home visiting programs have not yet had the opportunity to conduct the gold standard research multiple randomize controlled trials and longitudinal studies necessary to prove their effectiveness and the and the fact is no one size fits all families need and want a variety of supports and services and communities need and want the strategies that fit best for them we also are very concerned about the implementation challenges that many organizations have in learning to deliver these evidence based programs with fidelity to the model this is an area that requires the technical assistance and training that the legislation allows for in the set aside for those services there are many implementation challenges in moving our field to these goals in conclusion i would like to thank chairman dermot ranking member linder and the committee members for inviting us to speak with you today we fully support your efforts to advance home visiting legislation and are happy to provide more information as needed to inform your deliberations around house resolution two six six seven thank you again thank you for your testimony i forgot to say at the start your entire testimony will be entered into the record and we ask you to limit your comments to five minutes you were five minutes is six seconds which is almost perfect so i'm not it's putting anything on anybody and i would very close to where i live well i want to thank chairman mcdermott in the committee for inviting me to this morning and have this opportunity to discuss with you which was about what i think is important legislative lets legislation the president's decision to invest in for newborns in the congress his willingness to act on this decision demonstrates a commitment to an evidence informed public policy a commitment essential if we are to successfully confront complex problems such as child maltreatment although no legislation comes with absolute guarantees the early support for families act builds on an impressive array of empirical evidence and creates an implementation culture that emphasizes quality and continuous program improvement in my time this morning i want to briefly summarize this evidence base about the the program elements associated with more positive outcomes underscore the importance of using this legislation not simply to deliver a product but also to enhance learning with respect to the evidence the confidence in the early home based interventions rests on a diverse and expanding number of high quality program evaluations this includes the seminal work of david olds and his colleagues colleagues showing initial and long term benefits from early nurse home visitation when provided to first time moms early in their pregnancy the expanding research including both randomized clinical trials and other strong research designs that support the efficacy and efficiency of several national home visitation models serving more diverse populations and the ongoing investment  experimentation at the state and local level across this country to create the infrastructure necessary to ensure such services are sustainable integrated into existing health and early early education systems the consistent message from this large and growing body of research is that the chances of success regardless of the model are improved when programs have certain features to improve when their programs have solid solid internal consistency that links specific program elements to specific outcomes strong provider participant relationships that extend for a significant period of time to accomplish meaningful change in a parent's knowledge level skills and an ability to establish a positive attachment with her infant well trained and competent staff high quality supervision that includes observation of the home visitor interacting with the parent solid organizational capacity among those community agencies delivering the service and appropriate linkages to other community resources and support as congress moves forward towards developing this legislation these parameters rather than the utility of a given model or research design should guide your thinking unless all of the interventions supported by this initiative are structured around these these types of core practice principles the odds of success regardless of the model you use are greatly diminished second defining the evidentiary base necessary for estimating the potential impacts of a given intervention is complex as noted in a recent memo to o m b by the american evaluation there are no simple answers to questions about how well programs work and there is no single analytic approach or method that can decipher the complexities that are inherent within the program environment and assess the ultimate value of public programs given this reality this legislation should direct states to consider a model's full research portfolio not simply count the number of randomized clinical trials that have been done knowing a program can be implemented under ideal circumstances is not the same as knowing a program will achieve comparable effects when broadly in implemented with a more challenging population and in communities that are more poorly resourced fortunately the research base on which this legislation draws is much wider and more nuanced than a handful of clinical trials state planners should be directed to consider all facets of this database in a dentist buying those evidence based programs best suited to their service delivery context their community challenges and their at risk populations finally the x emphasis on evaluation and data documentation is perhaps its most important feature home visitation while promising does not produce consistent impacts in all cases not all families are equally equally well served by the model retention in long term interventions can be difficult training and retaining competent staff service providers is challenging particularly when the strategy is made widely available to diverse populations addressing these and similar questions requires that evidence based interventions be implemented not only in light of what we know but also in humble rect recognition of our obligation to do better improving our ability to a dentist i engage in effectively serve new parents facing the most challenging circumstances requires more than implementing a program doing better requires a research and policy agenda that recognizes the importance of linking learning and practice an issue to have must be implemented and assessed in a manner that maximizes both the ability of researchers to determine the efforts efficacy and the ability of program managers to draw on these data to shape their practice and policy decisions the early support for families act encourages and rewards innovation by providing state planners important  expand the pool of evidence based programs in ways that will strengthen outcomes for families improve service efficiencies and maximize social savings thank you thank you very much for just money our next witnesses dr brooks gooden who is thank you very much it's a pleasure to be here and pressing the members of this committee thank you chairman mcdermott mcdermott and ranking member linder i am a developmental psychologist by training i've been spending thirty years following families over time to see what circumstances help them do better and what circumstances impede success for both parents and children i've also been involved  evaluation and design of three different programs that are relevant to this hearing today the infant health and development program the early head start national evaluation and the home instruction for parents of preschool  youngsters affectionately known as hippie for understanding the review of literature what we know about how home visiting works i would suggest that all of you turn to the future of children this is nine two thousand and five and two thousand and nine i was involved in coauthoring the articles in two thousand and five and two thousand and nine but it gives you a really great history over time of what we found  what i want to do today is talk about the different strategies that we have for enhancing young families lives i'm particularly interested in young first time mothers they are the most vulnerable as are their children for later problems in life i'd like you to consider also several different kinds of outcomes that programs can have what we're concerned about for what i'll just call first time young mothers are their education success clearly we have to be worried about if we can enhance their education if we want long term impact on them or on their children the second is their parenting capabilities and capacities  and home visiting programs do address this part of this is child abuse and neglect but there are other aspects of parenting capabilities that we're interested in and of course the third is children's school readiness so how do these strategies that we have been looking at over the years stack up in terms of the outcomes that we think are important first home visiting programs that offer or air in conjunction with center based care do seem to have the ability to increase these young mothers education that's very important programs that are just home visiting programs alone in general do not increase parents education the nursing home visiting program is an exception to this almost all the programs that you will hear about do seem to influence parenting capabilities and capacities is very important when you look at the range of programs that exist these programs these effects are modest but they are consistent across programs very for you programs actually reduce the incidence of child abuse and neglect a variety of reasons for that that we can talk about later in terms of school readiness for the children when we're focusing on the children some but not all home visiting programs have shown that they can change the school readiness of children home visiting programs often target also child and health safety and seem to do a good job of targeting this some programs are able to change maternal mental all that's very very difficult to change in general so i also focus on the effectiveness factors in programs to try to get the outcomes that we want the effectiveness factors that i thought girl important for my review of the literature specific curriculum very intensive services home visiting programs that provide services less than weekly in general are not likely to be effective there are a couple exceptions to that but in general if it's not intensive it isn't probably not going to have an effect we need well trained staff this includes ongoing evaluation during the home visits themselves this is typically not done we need well educated staff my read of the literature is that programs using paraprofessionals are in general not likely to be effective when we compare these programs that use professionals and more educated staff and the services provided it's very important even in programs that are designed to be intensive intensive we have to make sure that  people receive the expected number of home visits so in summary we can make differences what kinds of programs should be be putting in place there are some home visiting programs that look like they will do what we want them to do i also would urge the committee to allow states to do some sort of demonstrations to see what happens when you combine home visiting with programs that offer these young mothers educational supports so that we can get the mothers to increase their education since this is a poorly educated group these first time young mothers states could also try combination programs if possible that combined with the best of home visiting with childcare otherwise if we don't try balls to keep the effectiveness factors in place we will not be able to  where you go thank you and good morning mr chairman and distinguished members of the committee my name is cheryl dupree and i am a family support worker in the healthy families america program serving madison county in new york it's a manner and a privilege to be here today to share my experience first as a participant in healthy families america and now as a home visitor for the program in one nine hundred ninety three my husband jeff and i were and my three year old daughter were presented with a new challenge i received the news that we would be expecting another baby and could welcome him in about seven and a half months i gently broke the news to my husband and together we sat in silence each struggling with our own fears and thoughts geoff had his mind on the already insufficient funds and how we were going to replace all the baby furniture we had just given away because we were convinced that we were already blessed and would not have any more children i was busy thinking about having to go through postpartum depression with another baby i had suffered with p p d for more than a year after the birth of my daughter i had no clue what w happening to me but i made it through that year with the patience of my husband and kind words from my family i was petrified of going through it again and the possibility of it worsening i had heard the horror stories in the news and i prayed i could remain well enough to take care of our children and hold things together at home visiting with a friend i expressed some of my concerns and she recommended i check into a home visiting program that was available in our county through the community action agency the program is called starting to gather which is part of healthy families america new york the program partners with families who have children prenatal to three to five years of age during my pregnancy she would meet with me weekly and jeff would join us whenever he got the chance she listened to me and she shared information with me she gave us the support i needed to not only feel like a competent parent to the child i already had but she helped me gain the confidence i needed to talk with my doctor about postpartum depression i was afraid that whichever doctor happened to be on call that day with the other just dismiss my concerns or tell me it's normal to have the baby blues after a baby comes through the information she brought me i now knew that it was much more than the baby blues and i was able to get the help i needed with medication and strong shoulders and i was on my way to a healthier life in a more secure attachment with my son once damian was born our home visitor brought us curriculum on the stages of development books and videos on basic care and information and community resources that helped our family stay afloat she left information on fatherhood for jeff so he could feel more confident and strong in the vital role that he played in our lives throughout the course of three years we spent time together doing activities with the kids setting attainable goals for my family and spending countless hours of just talking we talked about everyday stresses and at that point there were plenty of the s we also spent time about talking about my life and what it was like growing up she gave me the opportunity to tell my story and i came to see that i too was worth listening to she laughed with me on the good days and she let me cry on the bad days that were so overwhelming i barely get one foot on the floor but i put that foot on the floor because i knew she was coming to visit it meant so much to me that she understood the importance of nurturing the parent as well as the child when damian turned three my family graduated out of the program jeff was working two jobs i was now working full time and our daughter was honing the skill of bossing our baby brother around the job i was doing was on fulfilling but it helped pay the bills our last home visit our support worker encouraged me to apply for an open position at the program as a home visitor after all she had taught me and all the ways our family had benefited from the program i was excited about applying for the job i was anxious to start lending a helping hand a supportive ear to other parents one of the greatest gifts that she gave me was the belief in myself and i was lucky enough to have the program see my strengths as well and i was offered the position my home visiting career started out with many many months of training and researching community resources so that i could be equipped to meet the diverse meet needs of each family the very heart of healthy families america is programming healthy parent interaction and child development while on the floor doing activities together we also discuss life challenges such as housing employment accessing medical care transportation offering referrals and brainstorming ways to remove the barriers that families feel interfere with their success is a key part of our visits one reason example is i visited a young single mother with relationship challenge and and in sufficient income i referred to a child care center which she enrolled her child in enabling her to go to work once she had stable income we were able to connect her to a first time home buyers program which provided her with five anshul education to make sure home ownership is appropriate for her i'm happy to report that she is still successfully employed and does own our own home outcomes can be amazing when supports are identified and goals are trainable so here i am in eight years and a few home visits later and i'm still learning about the benefits and the power of presented a program and my passion to partner with families is as strong as ever my home visit with low income families no income families and middle class families who are now finding themselves in positions they had never been in before they all have a multitude of stresses and some just need another adult to talk to each having their own story worth listening to each craving the opportunity to learn and grow and each deserving to be nurtured the common bond with each and every one of these families including myself is their child we all want the best for them and we want more than anything a mess to be the ones to give it to them i have seen both sides of what a home visiting program can accomplish and it's so much more than life changing its life and hansing so i thank you today from the bottom of my heart for your time and your own visitation and sharon sprinkle and i work as a nurse goes out to where the nurse family partnership national service office i've been fortunate to serve in many different capacities for north family partnership as a nursing home visitor nurse supervisor and now as a nurse consultant integrating the knowledge and skills from our earlier rows to help guide and support our nurses in minutes traders and agencies to successfully deliver program services i am here in support of the obama administration's proposed initiative to create a new evidence based home visitation program for low income families i would like to thank chairman mcdermott congressman davis and members of the subcommittee for their commitment to improving the health and well being of children we've dedicated funding for evidence based home visitation and our family partnership program model has served almost one hundred thousand families today and we currently have over eighteen thousand first time families and rolled in twenty eight states our voluntary program provides home visitation services by registered nurses to low income first time mothers beginning early and they're playing a cd and continuing to through the child second year of life the children and families we serve are overwhelmingly young poor and minority our families are at the highest risk of experiencing significant health educational and employment disparities that have lasting negative impacts on their lives and communities and our family partnership pairs three major goes they are to improve pregnancy outcomes improve child health and development and improve parents economic self sufficiency you know stanley partnership is an evidence based program with mol tied generational outcomes that have been demonstrated in three randomized controlled trials conducted in both urban and rural location and with caucasians african americans and hispanic families a random control trout is the most rigorous research method for measuring the effectiveness of an intervention in a family partnership model has been tested for over thirty years going through with ongoing research development and evaluation activities conducted by dr david all evidence from one or more of these trials demonstrates powerful outcomes including seventy nine percent reduction in preaching and deliveries to women who smoked fifty percent fifty six percent reduction in emergency loans visits by accidents and poisonings forty six percent increase in fatherhood involvement in the household fifty nine percent reduction in the rest of a child at age fifteen and seventy two percent reduction in a record by the mother of of the child at age fifteen as a nurse found the partnership model has moved from science to practice great emphasis has been placed on building the necessary infrastructure to ensure quality and fidelity to the research modeled on the replication process and nationwide independent evaluation says found that investments in the north valley partnership model lead to significant returns to six friday and governments for example the process of physics is the two for research and evaluation released a report in march of two thousand and nine which i would like to take this opportunity to share an experience i had as a nurse and a visitor while working with a client named allison grange borough north carolina alice became pregnant when she was fourteen and was cute caring for a child while living in an apartment with six siblings and her two parents she called me one morning because no one in her family could take her to her local with appointments when infants and children's going to car ride alice and for me that her household had not had power for  way but she didn't seem too upset by this development i knew immediately that alice and her family needed assistance identifying and connecting to community resources i call the department social services but did not get much of a response so i decided to contact a few local community nonprofits that would assist local low income families who are unable to pay for food and other vital services to organizations agreed to jo cover the electric bill and when i drove alice home i told her that she could tell her father that the power would be restored the next day up until this point in the real relationship with alice and her family alice's father was not very engaged and dorm i visit after the electricity was restored to the house this problem and said to me a lot of people say they will help but you're the one who really did it this is one of the many stories about the impact that it was family partnership had we can help break the cycle of poverty by empowering young mothers to become knowledgeable parents who can care for their children and guide them along to a half healthy life course the nurse family partnership  urges the subcommittee to devote resources to assist states in implementing acts and expanding their home visitation programs to serve even more vulnerable families we encourage the committee to target taxpayer resources to the poorest communities that often lack the critical maternal and child health and social resources to ensure the most at risk families succeed i would like to thank the subcommittee for inviting me to testify and i would also like th thank you very much for your testimony i'm going to start i think by letting mr linder ask first question because i want to think a little bit about what you've opened up so many possibilities i'm not quite sure that the staff questions are quite what i want to do so i'm a wait a minute thank you very much i i would like to ask a question of a sprinkle i see numbers of six thousand children are born to girls fourteen and younger each year in this country is the prospective mother your client or server family your client the mom is the client because when you improve parents a make a change in committed and motivated to make a change will better life for their check out the program as proposed is going to try to help four hundred fifty thousand people a year and i'm told that there's about one and a half million in the same in the same boat who picks and chooses  from our point of view as a state agency we look at a number of factors in turn but the primary one is the capacity of the local community the organization implementing organization to be able to identify from their perspective using data that's available on all sorts of measurements to be able to target the resources target the services to those most at need who are most able to be positively impacted so  how do you make that how does a scientist or an examiner make that decision you know the cost savings are determined by looking at a group of people who receive the service and those that didn't receive the service generally randomly assigned to these two conditions and then you look at their experiences in utilizing public resources going forward in the case of the nurse family partnership they have eight hundred twenty years of evidence and what you find in the individuals who have received services there's less welfare utilization there's less use of public health care dollars because there greater employment and that occurs because as is gene noted they stay in school longer and they complete their education till it begins a cycle of investment in their themselves such that the social savings can be realized down the line  cost about two billion over five years the proposal in the about obama budget would cost nine billion over ten years in just federal funds for this new program today the president's going to speak on urging us to pay for all new basically slater's this one should decide what good public policy is and once you've decided what good public policy is then you decide are you going to pay for it i think that what we're trying to do you decide today here is what's the best public policy and you're correct finding the money for is going to be a real problem a doctor books books a gun can any of this money in this program be used for anything else going to be used  state that the state option you're going to have to you guys are the ones that will have to decide if there's some state flexibility flexibility thank you flexibility in terms of how the money is spent there isn't no well at the moment most come visiting programs because of cost do not offer drug treatment other people certainly try to link up their clients with what might be available in their community for mental health services and for drug treatment services thank you thank you michelle my question is this and it really comes off what janice said and and i read all your testimony before you came in and i want you for one minute to think about the perfect program and what it would look like because as i look at it you can do prevention you can sort of say well there's a high risk bunch over there let's focus on them or we can sort of one look for the ones like ms dupree who have had some problems and put their hand up and say high risk you can there's a lot of different ways to go at yes and are you looking at first time mothers if you had limited dollars where would you put the program what would it look like i'd like to hear as much as you can give me so you can start anywhere but i will put their hand up and go on that they were shy i think if i were starting with a with some dimensions i would certainly begin to look during pregnancy begin to with and do a systematic assessment not necessarily of you simply demographic markers for this because i think as we've heard from shelf testimony using just the demographic markers are going to miss a number of women that are there are facing significant challenges that would be prenatally remember these programs are all voluntary so you need to present them in a way that's most welcoming and encouraging for families to come forward so i'd start with a systematic assessment at all prenatal clinics i would engage o b g y n so that they were asking a set of questions when women came to them and then make this service available to people again i think i've outlined the parameters of what a successful program would look like but the idea of targeting simply on demographics i think does a great disservice to the nature of the problem into the nature of our ability to really reach those families that are most challenged and how would you well let's leave it alone for say doctor i would probably start with the you know any program that has any kind of positive predictive capacity to pick out child abuse situations before they happen the sprinkle you're on the field what would be the ideal program to deal with what you've seen a function associated with the program so that we can build the pipeline of programs that can eventually get the research and evaluation to establish their effectiveness i agree otherwise with these of which there were three across three different decades using three different ethnic groups caucasians to elmira new york african americans the mrs and hispanics in denver colorado he did  a form if you will ask in potential participants or members in a community who will be most stressed in terms of letting you into their home and overwhelmingly it was nurses  the trust of the community and seen as nurturing individuals who have been there to support them to have the medical and scientific knowledge to support them on such a critical time in pregnancy do you all agree  with i'll make a quick comment and i would just like to say that certainly nurse delivered programs have been proven very effective i'll just reiterate the point of my testimony which is many programs have been not had the opportunity to have the same level of rigorous evaluation so they are there i think that there is some evidence still out on that issue thank you dr brooks did you want to comment yes if if we can expand to other countries besides the united states my read of the literature is that what is important is a professional not necessarily and nurse depends on the goals of the program the nurse family partnership has very specific goals and so the nurse makes sense but i think that there are demonstrations in the literature where social workers educators folks with b a s with terrific training can have some of the impacts we want to see my read of the literature is that the pair of professionals in general those are the programs that are least likely to succeed thank you dr darrow you know i just said that we don't have to go overseas there are evaluations here in the united states in new york state which last time i checked was in this country does he has had success with paraprofessionals a lot of the success of the paraprofessional so hinge on the quality of training they receive and the supervision they receive so it's not sufficient just to say what's the characteristic of the provider it's the the way you embrace that surround that provider with certain supports and i think with certain supports they certainly can be effective i gathered from reading your testimony that there are a number of programs that are of questionable effectiveness others are been shown to be towards certain outcomes such as the nurse family partnership nurses baby affective but their own randomized trial comparing nurses in paraprofessionals fantomex results there were actually some outcomes where the paraprofessionals did better by the time the child was for areas like maternal employment areas like enrolling a child in an early education program those are important outcomes to consider when we're thinking about the long term potential savings on our ranking member talked about the cost and how how all this will be paid for given the current deficits and there's also another cost factor in all this and also expand disco particularly if we're looking at nurses and that is the acute nursing shortage we have in this country and given current circumstances and so if we expand with the new entitlement program that's going to be heavily reliant upon nurses then there's going to be the expense of getting more nurses available and training to do this and i'm not sure if that's included in the cost analysis that's  been provided i don't know if you want to comment on that that's one reason that many of us want to see some experimentation with different programs so as an example we have a grant tending it and will see if we get it to take the nurses home visiting model and have nurses come into the home two or three times over the three years and then have folks with b a delivering the services the idea was to get what you get from a nurse some visiting program but make it cheaper leverage of the nurse we want to leverage and this is something again that you know as the field evolves we have to keep looking to see what makes sense to me and david olds is going to help us with this the seems like a really good bet to see if this would work but one last question if you might there are a lot of different programs out there a lot of different funding sources given the variation in the fact of this there's or been any any systematic look at some of these programs are not really effective and how do we combine resources rather than creating a whole new mandatory spending program the way the legislation is is crafted which is actually very very instructive and very useful is to direct states towards investing in more stronger and stronger program models as the legislation goes forward and i think that's important i think states themselves local communities as a field we need to be able to read those programs that are now working and then move them off the plate so that those resources can be invested in programs that have stronger evidence but before increasing spending again in a new mandatory spending program should we look at the current resources and tried to make more efficient use of those i'd like to state as someone responsible for administering public dollars that we did in fact cut funding from programs in our state based on lack of performance and i think a responsible administrating entity would be looking at those this is after some attempts were made to make sure they had the capacity and built the capacity to be able to deliver programs effectively but when that became when it became clear that was not going to be the case then we were able to remove funding based on these performance based contracts how many programs  in a relatively small number of the total portfolio and in some cases it was a lot issue at the community level in terms of local capacity to continue to come up with the resources to to to match our dollars  but there are also just some straight out not delivering program of facilities or the model is a better fact being straying far afield and those are the kind of things that a funder or administrator would want to make sure they were looking at along with a number of issues that relates to the well being and children and ultimately to the well being of our country you know i've always believed that one all of us are the sum tolls of our experiences and i've spent at least five hundred home visits with visiting nurses with community healthy with nurse practitioners with individuals in training to become nurse practitioners and i agree with you misprint i don't think that there is any one set of individuals who necessarily get the information or see certain kind of need or can make use of those needs in such a way that we ultimately reduce the likelihood that children growing up or that their families are going to cost society more than they would if we provide these services to them my question is is this based upon each one of your experiences who do you think are the people that are most likely to make use of this program and these services once we  and the money get established to the people who are going to make use of it perhaps we'll just begin with you michelle ok i'll start with that my not read read of the literature and understanding of the program services one issue becomes very clear and that is the issue of engagement if families if individuals families moms dads are not engaged brought into  the program with a consistent with the values within the program in other words respect and honesty all those other things that go along with this then you're not going to have success in the program by any measure because engagement is a critical part of that and retention is the other side of the engagement process so i think the programs all of these programs are challenged by by those issues of reaching out and finding the people who would have the greatest benefit but i do trust the local implementors of these programs to know their communities well enough to be able to reach deeply into the community to find those with the greatest need who would experience a greatest benefit you know having done several surveys on the idea of the social exchange process people are twice as likely to offer help as they are to ask for help so one of the things we have to do with voluntary prevention programs is create a context in which parents are comfortable asking for help and so who should ask for help i think parents should have questions about their own capacity to care and meet the needs of their child a first time parent that may not have the information they need or the knowledge  available and how to nurture and support that child or meet his basic care conditions families that are going through some particular stress in their own lives women that are concerned about their own safety there's a whole constellation of issues that need to be brought to the table but i would put the the the responsibility on both creating a context in which an offer of assistance will be receptive to people to someone hearing this and then brought make it broadly available let people know again starting at pregnancy through  birth many of the programs that have been most successful in reaching high risk families do a universal offer of assistance a universal visit if you say wow when a women are in the hospital delivering outlining a set of conditions and again making that office offer available to them it's from a personal perspective i don't think there's a parent out there that doesn't want to learn that doesn't want to experience someone supporting them whether it's your first child your second child i visit with a family who now is in their six child with two sets of twins under two and really asking for support and through the benefit the great is this type of intervention will be those families from low income vulnerable populations who don't have the advocates in place or the resources needed to access for assistance or even know to  assistance so increasing and an awareness of services that are available to them in the community i think will make great strides in getting families the services that they need thank you thank you mr roscoe chairman and thank each of one of you for your time today and as the precinct you very much for sharing your journey is helpful and it's insightful you know as we're sitting here listening i'm i'm reminded of my older brother who has no discernment when it comes to movies you call him up steve should i go see this movie oh yeah he says it's great you'll like it and you go see it and it's not very good and you call him up later and you say i thought you said this is good he goes well he was entertaining he has no discernment whatsoever he called my wife and say should i see this movie she says you know no magic no plot line they ran out of money they ended it too fast waste your time so as i'm here today i'm trying to discern more like my brother or more like my wife and you know the question is a serious one because you know here you are three of  own you misprint so the question is are there implicit in your testimony when you use an evidence based argument is that there's programs that you've looked at in this environment where you've said that's a loser we're not we're not going to do that you mentioned a minute ago there was a program or some kind of de minimus programs and putting words in your mouth a little bit but some stuff that because of a local match kind of waved with there certainly are i think there are programs that are not well conceived they're going to accomplish everything in the world with a family what are you going to do we're going to give them three home visits that's a no brainer for me it's not going to happen so i think you can look at the internal consistency of a program their logic model i think and then you look at outcomes if time and time again they can only engage a handful of the people they want to bring into the program the only retain people for a fraction of the time they want to keep them i think that kind of ongoing data management should begin to tell you this program needs to go back and retool it's not ready for prime time and there are unfortunately a number of programs that just crop up we call home grown programs attached to any of the national models they just exist because somebody thinks it's a great idea i think in this environment we can fund everybody's great idea  need to be able to pull the plug thanks for that i am supportive of programs that will improve lives of families in general particularly low income minority families because we know that they are with for the worst outcomes in terms of economics and health but most certainly you want to put your resources where you're going to get the greatest benefit pro programs they had a data tracking system that looks at my characteristics that looks at the quality of the home that looks at the content and has a curriculum if you will or protocol with the desire and intent to i don't want to i want to refocus you on this question have programs come across your experience they come across your desk that are home visitation programs know yes we have definitely look come across programs that we did not find the evidence persuasive asked for their effectiveness and we did not close include them on the list of those that we would fund and  we are we are committed to reviewing the literature and new evidence as it comes along but clearly there are some programs that that may even do harm one quick quick final word ms miss frankel you mentioned that in that example of the fourteen year old that you gave that there were people that that the family had reached out to that weren't willing to help and i guess part of the part of the concern that some of us have is how do we drive how do we direct programs that that are actually getting towards that particular need particularly so implicit in that is that some some program is failing this family right a well intentioned good program is failing this family and you know in light of president obama's speech and i have my staff i'm going to share with you one quick quote it's from his inaugural speech he said the question we asked today is not whether government is too big or too small but whether it works where the answer is yes we intend to move forward and where the answer is no programs will end so sort of that i guess in closing our challenge in light of a president who tells us that we're broke  you properly allocate resources how do we all properly allocate resources so that those families really need the help are helped and that there's not there's not a great deal of ways and i think that was why the ticket dr stanley was driving at taking  a step back looking at the totality of these programs and trying to move forward where there's a great deal of consensus and i think my time has expired since we have good experts  here we would go a second round if anybody would like to davis would you like to choir thank you very much mr chairman and i have a couple of additional questions and i guess part of my experience has been that i'm old enough to remember when a lot of things didn't really exist position assistance i have been a member of the of the new careers section of the american public health association when many of the ancillary groups who now provide certain kind of services did not exist i want to ask two questions dr darrow i want to ask you we've talked a great deal about stable funding although i agree with chairman mcdermott if we come up with a good social policy then we can determine how to get the money once decided that it's good but but why would is a stable funding school streams point in the development of a program like this when i think when you're talking about investing in newborns in their parents and you're trying to do it this scale large enough to impact the population based indicators that most distressed you like reducing child if you like making sure children arrive at school to learn families need to know that this isn't a program that's going to be here today and gone tomorrow they need to know that it's go there for them when they have their first child or their second child that they can refer their neighbors to it and too often programs that are quite good i mean one of the problems is it's not just not just poor programs in the marketplace it's good programs in the marketplace that have way too many families that they can't possibly reach or serve it's good programs in the marketplace that lose their foundation funding so they have to close their doors that does a disservice to the communities and that's why the stable funding is so important and so we talk a great deal about these things but do them much less i mean i was saying that suggests that after all is said and done was generally said than done and so there's a lot of conversation not movement to the action my last question was wrinkle i notice that you placed a great deal of emphasis on low income people why why did you place so much emphasis why do you place so much emphasis on low income disadvantaged low income disadvantaged individuals typically don't have the advocates needed to help them get the resources to meet their needs my experience growing up here in washington d c within walking distance from the capital here is an experience in which i grew up in a low income environment and those of the families that can benefit great is from this type of service and so you're saying that if we don't create special attention for these individuals was long as they live as long as their children live as long as their population group lives they'll still be low income disadvantaged lot ok thanks what happens i know my son's a counselor he does home visits and he finished with a masters degree and jumped into one program and it was very disorganized a lot of people are quitting there's no continuity of care with the families he went to another one same sort of thing and now he's doing something different in counseling but he's very frustrated said we're not going to make a dent in any of this because we're not measuring outcomes properly the continuity issue is or is is a real problem there's just no structure to either the programs to programs in my home state of louisiana of a lot of it's being funded by medicaid dollars states are struggling with their budgets across the country how many more of these kinds of programs are out there and how do you how do you root them out you talk about having a way of doing it in your home state but it well the other states are quick to do this so they do a very good job i guess i'd just like to add that our ability to sort through and make these performance based contracts work along with the capacity building goes back twenty years to our focus on outcome based evaluation we felt that as a fund or our best value add for these local organizations was to help them understand to be outcome based and to know how to measure and report those results and so that's been the key to their sustainability so it's part of our learning organization way of doing business to sort of focus on those kind of things and those can while it sounds very specific to a reporting process it actually is what builds the organizational capacity to deliver programs with effective service illiteracy model thank you senator moynihan has talked about all this back in the seventy's and you know breaking the cycle of poverty is something i'm  certainly interested in i've got a high degree of poverty my district and but frustrated because it seems like we throw a lot of money into programs that but yet yet never weed out the bad ones to celebrate the good ones and focus the resources as my colleague mr austin was saying earlier so i guess of one final question in the spirit of father father's day which is approaching what share of households are the fathers in the picture in this and what  can you talk to me about some of the best practices and what's happening there almost all of the models now have an explicit instruction as to visitors when they go in in the home to engage as many as they can and i think the nurse family partnership is a wonderful job with fatherhood i know healthy families america does and many of the other programs that are out there i mean people recognize that dads are a big part of the picture and they need to be there at the beginning hopefully engage during the pregnancy if at all possible like you the best way to the best way to do that actually could be programs that really start in the hospital we talk about the magic moment and that is when the child is born and you can often get fathers very engaged at that point whether or not they're in the household or they're living elsewhere in my experience in working in greensboro north carolina operate in a family partnership program we had a fatherhood component where the services were designed exclusively for the dad to get him involved in a life with a child early on and you can see the positive impact that it has on the child when the dad is involved if not physically present in the home emotionally present in a child's life included in the visit don't the time of the whole visit enough money for the ship and there are some programs that specifically i designed to serve fathers outside of that relationship with the mother because they have their own needs and resources we go out to visit a family for the first time we take the information about him and we set up a visit for the family with him and that is every single family what kind of outcomes you getting with getting the father involved you have you have some metrics on the i mean just kind of in general success rates and is a trend good or bad or neutral others i'll have to get back to you on that one ok it's going to have to be anecdotal interesting way there's not much in the literature about what's happening to the fathers but the function of home visiting program passed in the united states congress and the first mental health centers were opening across the country state of illinois the money went to every state it went to the governor except in illinois mayor daley got a chunk of it and i was at the university of illinois and it was there when we started the first mental health center in the woodlawn area south of the university of chicago it was an area that was troublesome to the mayor and he said well what they need is a mental health cent and so they sent a group of us down there to start a mental health center in in the woodlawn area and when they got together with the community they said to them what what do you want this mental health center to do and they said well it's over for us as adults but we care about our kids we want this middle center to focus on the kids and we did research for a number of years there around what effect school performance and how kids do and so forth and getting the parents involved in actually going up to school and actually seeing what the kids did it really was the most effective thing because suddenly they knew their parents cared about what was going think our committee has is to figure out which one of these evidence based programs or how we should put the money out there so that states will look at it in that way that that's we ought to take things that all of already been researched and implemented and give them a solid funding base which is really what david's talking about we start and stop them and one gets going it looks good and then we defunded and so i think that's what the committee is all both sides of the aisle here is really looking at is how can we figure out where the best place to put the money is and actually fun things that we know have had positive effect so you're thankful  we're all thankful for your coming here and spending the time trying to educate us and we will see what works in the future thank you for the meetings