TRIBAL MATERNAL, 

INFANT, AND EARLY 

CHILDHOOD HOME 

VISITING: 

A REPORT TO CONGRESS
 

OPRE Report #2015-88 

November 2015 
TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS 

OPRE Report #2015-88 

November 2015 

Kate Lyon, Erin Geary, Mariel Sparr, Brandie Buckless, Melina Salvador, and Julie Morales, James Bell 

Associates, Inc. 

Submitted to 

Aleta Meyer, Project Officer 

Office of Planning, Research and Evaluation 

Administration for Children and Families 

U.S. Department of Health and Human Services 

Contract Number: HHSP23320095644WC 

Project Director: Kate Lyon 

James Bell Associates, Inc. 

3033 Wilson Boulevard 

Suite 650 

Arlington, VA, 22201 

This report is in the public domain. Permission to reproduce it is not necessary. Suggested citation: Lyon, 

K., Geary, E., Sparr, M., Buckless, B., Salvador, M., & Morales, J. (2015). Tribal Maternal, Infant, and 

Early Childhood Home Visiting: A report to Congress (OPRE Report #2015-88). Washington, DC: Office of 

Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health 

and Human Services. 

This report and other reports sponsored by the Office of Planning, Research and Evaluation are available 

at http://www.acf.hhs.gov/programs/opre/index.html. 
  CONTENTS
 

1 Executive Summary ......................................................... 1
 

Tribal Home Visiting Promotes Family Resiliency and Positive Developmental Trajectories ....... 2
 

Tribal Communities Meet High Program Expectations ................................... 3
 

Required Grant Activities Build Grantee Capacity and Ensure Quality......................... 4
 

Early Program Successes: Grantees Expanded Home Visiting Services, Built Capacities, 

and Demonstrated Overall Program Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
 

Grantees Expanded Home Visiting Services to High-Need Families across 

Diverse Communities.............................................................. 7
 

Grantees Developed Expansive Capacities to Implement and Evaluate Home Visiting 

Cohort 1 Grantees Demonstrated Improvement in Key Determinants of Positive 

in Tribal Communities ............................................................. 8
 

Child and Family Outcomes......................................................... 9
 

Summary and Recommendations ..................................................... 12
 

2 Legislative Language ....................................................... 13
 

3 Purpose and Organization of the Report ....................................... 15
 

4 Background .............................................................. 17
 

A Strong Start: The Science of Early Childhood .......................................... 17
 

Supporting Families and Young Children: The Role of Home Visiting ........................ 18
 

Home Visiting in Tribal Communities .................................................. 19
 

Tribal Communities Experience Unique Challenges .................................... 19
 

Tribal Communities Possess Assets and Strengths ..................................... 19
 

Home-Based Support for Families through Traditional Cultural Practices................... 20
 

Formalized Home Visiting as a New Strategy in Tribal Communities....................... 20
 

An Opportunity to Support and Learn from Tribal Communities.......................... 21
 

5 Overview of the Tribal Home Visiting Program .................................. 23
 

Description of the Program .......................................................... 23
 

Activities Supported by Grant Funds .................................................. 26
 

iii 
iv TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Needs and Readiness Assessments ................................................. 26
 

Comprehensive Implementation Planning............................................ 27
 

Providing High-Quality Evidence-Based Home Visiting Services .......................... 28
 

Benchmarks .................................................................... 28
 

Rigorous Evaluation .............................................................. 29
 

6 Description of the Grantees ................................................. 31
 

Home Visiting Models Selected by Grantees.......................................... 31
 

Cultural Enhancements and Adaptations to Home Visiting Models ....................... 34
 

Populations Targeted by Grantees to Receive Services ................................. 35
 

Descriptions of Tribal Home Visiting Program Grantees................................. 35
 

Cohort 1 Grantees (FY 2010–2016).................................................... 36
 

Choctaw Nation of Oklahoma ...................................................... 36
 

Fairbanks Native Association....................................................... 37
 

Kodiak Area Native Association..................................................... 38
 

Lake County Tribal Health Consortium, Inc. ........................................... 38
 

Native American Community Health Center, Inc. ...................................... 39
 

Native American Professional Parent Resources, Inc. ................................... 39
 

Northern Arapaho Tribe........................................................... 40
 

Port Gamble S’Klallam Tribe ....................................................... 40
 

Pueblo of San Felipe.............................................................. 41
 

South Puget Intertribal Planning Agency ............................................. 42
 

Southcentral Foundation .......................................................... 42
 

White Earth Nation .............................................................. 43
 

Yerington Paiute Tribe ............................................................ 43
 

Cohort 2 Grantees (FY 2011–2016).................................................... 44
 

Confederated Salish and Kootenai Tribes............................................. 44
 

Eastern Band of Cherokee Indians .................................................. 44
 

Native American Health Center, Inc................................................. . 45
 

Riverside-San Bernardino County Indian Health, Inc. ................................... 45
 

Taos Pueblo..................................................................... 46
 

United Indians of All Tribes Foundation .............................................. 46
 

Cohort 3 Grantees (FY 2012–2017).................................................... 47
 

Cherokee Nation................................................................. 47
 

Choctaw Nation of Oklahoma ...................................................... 48
 

Confederated Tribes of Siletz Indians................................................ 48
 

Inter-Tribal Council of Michigan .................................................... 48
 

Red Cliff Band of Lake Superior Chippewa ............................................ 49
 

Yellowhawk Tribal Health Center ................................................... 50
 

7 Technical Assistance Provided ............................................... 51
 

Support from ACF Federal Staff Members .............................................. 52
 

TA from Model Developers .......................................................... 52
 

TA from the Programmatic Technical Assistance for Tribal Home Visiting Center............... 54
 

TA from the Tribal Home Visiting Evaluation Institute .................................... 55
 
CONTENTS v 

8 Tribal Home Visiting Services: Building Programs To Reach High-Need Families ....... 57
 

Increased Program Reach and Capacity ................................................ 57
 

Prioritizing the Highest-Need Families ................................................. 59
 

9 Fulfilling the Promise of the Tribal Home Visiting Program ........................ 65
 

Monitoring Program Performance in Benchmark Areas ................................... 65
 

Prevention of Adverse Experiences: Child Injuries; Abuse, Neglect, or Maltreatment; 

Grantee Improvements in Child Injuries, Abuse, Neglect, or Maltreatment 

Strengthening Systems of Care: Coordination and Referrals for Other 

Grantee Improvements in Coordination and Referrals for Other Community 

Grantee Performance Measurement Plans ............................................. 66
 

Developing Performance Measurement Plans and Grantee Capacities .................... 66
 

Cohort 1 Grantee Program Performance ............................................. 68
 

Overall Improvement ............................................................... 71
 

Individual Benchmark Area Improvements ............................................. 71
 

A Healthy Foundation: Maternal and Newborn Health ................................. 71
 

Grantee Improvements in Maternal and Newborn Health .............................. 72
 

and Emergency Department Visits.................................................. 75
 

and Emergency Department Visits.................................................. 75
 

A Path to Success: School Readiness and Achievement................................. 77
 

Grantee Improvements in School Readiness and Achievement........................... 77
 

Safe and Healthy Families: Crime or Domestic Violence................................. 80
 

Grantee Improvements in Domestic Violence ......................................... 80
 

Increased Resiliency: Family Economic Self-Sufficiency ................................. 82
 

Grantee Improvements in Family Economic Self-Sufficiency ............................. 82
 

Community Resources and Supports ................................................ 84
 

Resources and Supports .......................................................... 84
 

Why is Improvement in Benchmark Areas Important? .................................... 87
 

10 Findings, Lessons Learned, and Recommendations .............................. 89
 

Report Findings.................................................................... 89
 

Grantees Built Program Capacity to Successfully Implement Evidence-Based 

Tribal Communities Can Meet and Exceed the Federal Home Visiting Program’s 

Tribal Grant Programs Are Successful When They Intentionally Emphasize 

Successful Evidence-Based Initiatives in Tribal Communities Must Build on 

Tribally and Community Driven Programming and Decision Making Are Key 

Grantees Served High-Need Families Across Diverse Community Contexts ................. 90
 

Home Visiting ................................................................... 91
 

Grantees Used Innovative, Community-Specific Strategies to Overcome Challenges ......... 93
 

Grantees Built Strong Foundations for Early Childhood Systems of Care ................... 94
 

Evidence of Progress: Grantees Improved Program Performance ........................ 96
 

Lessons Learned ................................................................... 97
 

High Expectations................................................................ 97
 

Relationship Building and Capacity Building .......................................... 97
 

Principles of Implementation Science ............................................... 98
 

to Promoting Innovation .......................................................... 99
 
vi TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Evidence-Based Initiatives in Tribal Communities Can Be Strengthened 

by Support for Adaptation and Enhancement ........................................ 100
 

A Systems-Building Emphasis Is Critical for Strengthening and Sustaining 

Tribal Early Childhood Programs ................................................... 101
 

Summary and Recommendations .................................................... 101
 

References.................................................................. 103
 

Appendix A Grantee Benchmark Improvement.................................... 111
 

Background ..................................................................... 111
 

Legislative Requirements ........................................................ 111
 

Interpretation of Requirements ................................................... 112
 

Discussion ....................................................................... 114
 

Decision Rules for Assessing Improvement .......................................... 114
 

Limitations .................................................................... 115
 

Appendix B Identifying Constructs for Data Aggregation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
 

Variability in Performance Measures ................................................ 117
 

Method of Data Aggregation ........................................................ 117
 

Identifying Constructs with Similar Performance Measures............................... 118
 

Identified Constructs and Number of Grantees Represented.............................. 118
 

Appendix C Limitations of Benchmark Data ...................................... 121
 

A Range of Local Challenges that Led to Sometimes Inconsistent and Incomplete Data ....... 121
 

Service Provision to Small Communities Led to Small Sample Sizes ........................ 122
 

Required Performance Constructs Did Not Account for Variation in Model or Program Focus... 122
 

Lack of Assessment Tools Validated with Tribal Communities ............................. 122
 

Benchmark Data Can Demonstrate Program Improvement Not Impact ..................... 123
 

Short Timeframe for Demonstrating Improvement...................................... 123
 

Appendix D Data Tables....................................................... 125
 

DGIS Demographic and Service Utilization Data ........................................ 125
 

DGIS Performance Measurement Data................................................ 135
 

Appendix E Summary of Tribal MIECHV Benchmark Performance Measures............ 141
 

Introduction and Overview ......................................................... 141
 

Summary Across Measures ......................................................... 142
 

Summary of Benchmark Domains ................................................. 142
 

Summary of Benchmark Constructs with the Highest Degree of Similarity ................ 145
 

Summary of Benchmark Constructs with the Highest Degree of Diversity ................. 145
 

Construct-Specific Summaries ....................................................... 146
 

Benchmark Domain 1: Maternal, Newborn, and Child Health .......................... 146
 

Benchmark Domain 2: Child Injuries; Child Abuse, Neglect, or Maltreatment; 

and Emergency Room Visits ...................................................... 149
 

Benchmark Domain 3: School Readiness and Achievement ............................ 151
 

Benchmark Domain 4: Crime or Domestic Violence .................................. 155
 

Benchmark Domain 5: Family Economic Self-Sufficiency............................... 156
 

Benchmark Domain 6: Coordination and Referrals for Other Community 

Resources and Supports ......................................................... 157
 
CONTENTS vii

List of Figures

Figure 1-1. Growth in Participants.......................................................... 8

Figure 1-2. Growth in Home Visits.......................................................... 8

Figure 1-3. Percentage and Number of Grantees Improved Overall and in Individual 

Benchmark Areas ....................................................................... 9

Figure 6-1. Map of Grantee Locations...................................................... 32

 Figure 8-1. Growth in Participants......................................................... 58

Figure 8-2. Growth in Home Visits......................................................... 58

Figure 8-3. Family Income Relative to Federal Poverty Guidelines, 2014 ......................... 60

Figure 8-4. Child Participant Age, 2014..................................................... 60

Figure 8-5. Adult Participant Age, 2014 .................................................... 61

Figure 8-6. Type of Adult Participant, 2014 ................................................. 61

Figure 8-7. Participant Marital Status, 2014................................................. 61

Figure 8-8. Participant Employment, 2014 .................................................. 62

Figure 8-9. Participant Student Status, 2014 ................................................ 62

 Figure 8-10. Participant Educational Attainment, 2014........................................ 62

Figure 8-11. Percentage of Newly Enrolled Families in Priority Populations, 2014.................. 63

Figure 9-1. Percentage and Number of Grantees Improved Overall and in Individual 

Benchmark Areas ...................................................................... 71

List of Tables

Table 6-1. Grantee Service Population Locale ............................................... 31

Table 6-2. Overview of Selected Home Visiting Models ....................................... 32

Table 6-3. Home Visiting Models Selected by Grantees ....................................... 34

Table 6-4. Grantees by Cohort............................................................ 35

Table 7-1. Technical Assistance Provided by Home Visiting Model .............................. 52

Table 9-1. Benchmark Areas and Number of Constructs....................................... 66

Table 9-2. Constructs and Measures Identified for Data Aggregation ............................ 70

Table 9-3. At a Glance: Grantee Improvement in Maternal and Newborn Health .................. 74

Table 9-4. At a Glance: Grantee Improvement in Child Injuries; Abuse, Neglect, or Maltreatment; 

and Emergency Department Visits ........................................................ 76

Table 9-5. At a Glance: Grantee Improvement in School Readiness and Achievement .............. 80

Table 9-6. At a Glance: Grantee Improvement in Domestic Violence ............................ 81

Table 9-7. At a Glance: Grantee Improvement in Family Economic Self-Sufficiency ................ 84

Table 9-8. At a Glance: Grantee Improvement in Coordination and Referrals for Other Community 

Resources and Support ................................................................. 86
viii TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Frequently Used Acronyms
 

ACF Administration for Children and Families 

AIAN American Indian or Alaska Native 

CQI Continuous Quality Improvement 

DGIS Discretionary Grants Information System 

FS Family Spirit 

FY Fiscal Year 

HHS U.S. Department of Health and Human Services 

HIPPY Home Instruction for Parents of Preschool Youngsters 

HomVEE Home Visiting Evaluation of Evidence 

HRSA Health Resources and Services Administration 

MIECHV Maternal, Infant, and Early Childhood Home Visiting Program 

N Sample size 

NFP Nurse Family Partnership 

PAT Parents as Teachers 

PATH Programmatic Technical Assistance for Tribal Home Visiting Center 

P-CAP Parent-Child Assistance Program 

PIP Positive Indian Parenting 

SCA SafeCare Augmented 

SSA Social Security Act 

TA Technical Assistance 

TEI Tribal Home Visiting Evaluation Institute 
 

 

   1 EXECUTIVE SUMMARY
 

The Tribal Home Visiting Program, part of the Maternal, Infant, and Early Childhood 

Home Visiting Program (MIECHV, the Federal Home Visiting Program), is an 

unprecedented expansion of culturally responsive services for vulnerable American 

Indian or Alaska Native (AIAN) families and children, strengthens tribal communities, 

and contributes to more comprehensive and integrated systems of care for families 

and young children. Since 2010, the Tribal Home Visiting Program expanded home 

visiting services in tribal communities, serving a total of 1,523 families and providing 

nearly 20,000 home visits. The Tribal Home Visiting Program serves some of the 

most vulnerable families who experience multiple challenges—such as substance 

abuse, domestic violence, and poverty—often attributed to historical trauma. 

Required grant activities are based on implementation science and closely mirror 

the high expectations of State Home Visiting grantees. These requirements ensure 

program services are responsive to unique community and family challenges and 

support high quality program implementation. This is evidenced by a majority (77 

percent, n =10) of the 13 Cohort 1 grantees demonstrating overall improvement in 

the six legislatively mandated benchmark areas. Key predictors of positive child and 

family outcomes, such as increased prenatal care and screening rates for maternal 

depression and decreased rates of child maltreatment have improved. In addition to 

program improvements in benchmark areas, grantees built capacities for developing, 

implementing, and evaluating home visiting services. Capacity building efforts translate 

well beyond immediate home visiting services, benefitting the broader community 

through enhanced systems of care, workforce development, greater data collection 

capacities, and increased ability to advocate for and serve families and young children. 

Additionally, new ground is being broken in testing adaptations and enhancements 

to national home visiting models through locally designed rigorous evaluations that 

expand and strengthen the evidence base on home visiting with tribal communities. 

This report focuses primarily on the efforts of Tribal Home Visiting grantees. A separate 

report provides more details on the activities of State Home Visiting grantees. 

1 
2 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

TRIBAL HOME VISITING PROMOTES FAMILY 

RESILIENCY AND POSITIVE DEVELOPMENTAL 

TRAJECTORIES 

Supporting families with young children is an essential component of a 

comprehensive system of care for the nation’s children (Daro, 2009; Garner, 

2013). Home visiting programs use home visits as a primary delivery strategy 

to support pregnant women, expectant fathers, and parents and caregivers of 

children from birth to kindergarten entry. Home visiting helps expectant families 

and families with young children provide stimulating early learning environments, 

nurturing relationships, and healthy family functioning for their children. These 

factors, in turn, have profound effects on children’s physical, social-emotional, 

and cognitive development. A wide range of short- and long-term child and 

family outcomes improve, including positive cognitive and language outcomes 

for children, efficient family use of health services, positive changes in parenting 

attitudes and behaviors, and reduced child maltreatment and abuse (Daro, 

2006; Wagner et al., 2001; Raikes et al., 2006; Guterman, 2001; Home Visiting 

Evaluation of Evidence [HomVEE], 2014). 
EXECUTIVE SUMMARY 3 

The Tribal Home Visiting Program is well suited for addressing distinct challenges 

tribal communities face. Compared with the general U.S. population, AIAN 

communities disproportionately experience negative health outcomes, which 

may result from limited resources and access to services, unemployment, 

pervasive drug and alcohol abuse, poverty, and low educational attainment 

(CDC, 2011; King et al., 2009; Duran & Duran, 1995). Longitudinal studies also 

show that AIAN children often fall behind their peers across developmental 

domains at kindergarten entry, gaps that persist through elementary school 

(Demmert et al., 2006). These disparities are attributed to historical trauma—the 

collective emotional and psychological suffering endured by a massive group, 

manifesting throughout the life span of group members, and passed down 

through generations (Brave Heart et al., 2011). While tribal communities face 

these unique challenges, they also possess undeniable community assets and 

strengths. The Tribal Home Visiting Program leverages these assets and strengths 

by integrating community-based knowledge to promote positive child and family 

outcomes. 

Overseen by the Administration for Children and Families (ACF) in collaboration with 

the Health Resources and Services Administration (HRSA), the following are the goals 

of the Tribal Home Visiting Program (HHS, ACF, Office of Child Care, no date): 

1.	 Support the development of happy, healthy, and successful American Indian and 

Alaska Native (AIAN) children and families through a coordinated home visiting 

strategy that addresses critical maternal and child health, development, early 

learning, family support, and child abuse and neglect prevention needs 

2.	 Implement high-quality, culturally relevant, evidence-based home visiting 

programs in AIAN communities 

3.	 Expand the evidence base around home visiting interventions within AIAN 

populations 

4.	 Support and strengthen cooperation and promote linkages among various 

early childhood programs, resulting in coordinated and comprehensive early 

childhood systems 

Tribal Communities Meet High Program Expectations 

Congress authorized the Federal Home Visiting Program through a provision in 

the Patient Protection and Affordable Care Act of 2010 authorizing $1.5 billion in 

funding over five years. The Federal Home Visiting Program supports voluntary, 

evidence-based home visiting programs for expectant families and families with 

young children up to kindergarten entry. As an evidence-based policy initiative, 

the Federal Home Visiting Program prioritized funding to implement home visiting 
4 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

models that have solid evidence of success. Additionally, legislation requires 

grantees to engage in several program activities, including: (1) completing needs 

and readiness assessments, (2) implementing evidence-based home visiting 

services, (3) collecting and reporting benchmark data, and (4) conducting rigorous 

evaluation of promising approaches.

Legislation set aside three percent of these funds for eligible Indian tribes, tribal 

organizations, and urban Indian organizations—hereafter referred to as the Tribal 

Home Visiting Program. This legislation specified that “to the extent practicable,” 

tribal grantees adhere to the same high standards and expectations of the Federal 

Home Visiting Program with regard to required program activities (Sec. 511, SSA). 

HHS drew on this legislative language to ensure that the Tribal MIECHV program 

was implemented with high standards but also had flexibility to be tailored to the 

unique needs and realities of tribal grantees. One area that this “to the extent 

practicable” language supported flexibility in implementation was with respect 

to implementing evidence-based program models. While a systematic review 

of evidence of effectiveness for the Federal Home Visiting program identified 

program models with demonstrated effectiveness, it did not find any home 

visiting model to have evidence of effectiveness for tribal populations. With the 

exception of one program model,1

 The Family Spirit home visiting intervention met criteria for evidence of effectiveness with tribal communities in a 

2014 update of the HomVEE systematic review. 

 program models deemed evidence-based for 

the Federal Home Visiting Program are considered promising approaches when 

used in tribal populations. Therefore, all tribal grantees are required to complete 

rigorous local evaluations to expand the knowledge base on home visiting in tribal 

communities.

REQUIRED GRANT ACTIVITIES BUILD GRANTEE 

CAPACITY AND ENSURE QUALITY

Required grant activities draw from implementation science to ensure quality 

program implementation. Grant activities were introduced to grantees in stages 

and in alignment with commonly identified phases of program implementation 

and associated drivers of high-quality program implementation. Required 

grant activities—from needs and readiness assessments, comprehensive 

implementation plans, to program monitoring efforts—ensure implementation 

and sustainability of high-quality home visiting services.

Provision of initial and ongoing technical assistance supports capacity building. 

Grantees received initial and ongoing technical assistance from multiple entities 

to assure necessary program infrastructures and capacities were in place. 

1
 

 

EXECUTIVE SUMMARY 5 

Technical assistance on a range of topics—from needs assessment, model 

selection, and implementation to performance measurement, evaluation, and 

continuous quality improvement — were also provided. 

Grants are awarded though cooperative agreements to provide ongoing federal 

support. Funding for tribal grantees is provided in the form of cooperative 

agreements to ensure flexibility in meeting unique tribal needs and contexts 

and developing program infrastructure. The cooperative agreements with ACF 

allow for extensive federal support on grant administration and management, 

implementation and service delivery, data collection, continuous quality 

improvement, and rigorous evaluation plans. 

Grantees engaged in comprehensive program planning efforts to develop 

implementation plans. Grantees engaged in thoughtful, iterative planning to 

build program infrastructures. This work included ongoing collaborations with 

community leaders and partner agencies to strengthen broader early childhood 

systems and provide coordinated services. They also hired and trained program 

staff, developed capacities to collect and report program performance data, and 

developed plans for continuous quality improvement. For many grantees, planning 

phases also included increasing community awareness of and support for home 

visiting as an effective strategy for improving the 

lives of families with young children. Additionally, 

each program completed a needs and readiness 

assessment to carefully select the model that 

would meet the needs of its community and 

ultimately improve the well-being of children and 

families. Grantees also worked with the developers 

of selected home visiting models to adapt and 

tailor models to their unique cultural contexts. 

Development of performance measurement 

plans enhanced program capacities and 

infrastructures for data collection and program 

performance monitoring. Legislation requires 

grantees to establish quantifiable, measurable 

benchmarks to demonstrate program 

improvements in six areas: 

1.	 Maternal and newborn health 

2.	 Child injuries, child abuse, neglect, or 

maltreatment and emergency department 

visits 
 

 

6 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

3. School readiness and achievement 

4. Crime or domestic violence 

5. Family economic self-sufficiency 

6. Coordination and referrals for other community resources and supports 

Development of performance measurement plans detailed the approach for 

collecting, analyzing, and reporting performance data in six benchmark areas. As 

part of this process, data collection and management protocols, analysis plans, and 

data systems capable of housing and linking data across programs were developed. 

Developing performance measurement plans and necessary systems of support 

was a new endeavor for many grantees and communities. As a result, program 

and community capacities were enhanced and benefited the Tribal Home Visiting 

Program, the broader community, and future community effort. For example, the 

program provided community members with significant opportunities for personal 

and professional growth. Grantees reported data on program performance 

measures using the Discretionary Grant Information System—Tribal Home Visiting, 

the first national data system for home visiting in tribal communities. 

The Tribal and State Home Visiting Programs gave grantees the flexibility to 

develop locally meaningful performance measures. As noted above, legislation 

required grantees to demonstrate improvement in the six performance 

measurement areas by improving on a majority of the specific constructs that 

constitute each of these areas. Within each of the constructs, grantees were 

responsible for defining their own performance measures and developing a 

strategy for collecting the necessary data. Specifically, grantees determined 

performance indicators (including a unique numerator and denominator for each 

measure), the definition of improvement, target populations for each measure 

(e.g., pregnant mothers), the assessment or screening instrument to be used, and 

the data collection schedule. 

This process supported ACF goals of encouraging local decision making and 

capacity building, but it required a time- and resource-intensive planning 

process for grantees. Locally meaningful performance measures also resulted 

in data that are difficult to summarize across grantees.2

 ACF is currently 

redesigning the performance measurement requirement based on lessons 

learned and grantee feedback from the first five years of the program. 

Under the new requirement, data will be collected and presented in a more 

standardized way across grantees. 

2

 Chapter 9 as well as Appendix B provide a more detailed description of how data were summarized in this report. 
 

EXECUTIVE SUMMARY 7 

EARLY PROGRAM SUCCESSES: GRANTEES EXPANDED 

HOME VISITING SERVICES, BUILT CAPACITIES, AND 

DEMONSTRATED OVERALL PROGRAM IMPROVEMENT 

Highlights of early Tribal Home Visiting Program successes include the following: 

1) Tribal Home Visiting Program’s substantial expansion of home visiting services 

across diverse tribal communities and high-needs families 

2) Grantees’ capacity building for developing, implementing, and evaluating 

home visiting 

3) Overall program improvement by a majority of the 13 grantees in the first 

cohort (77 percent, n = 10) 

Grantees Expanded Home Visiting Services to High-Need

Families across Diverse Communities 

Diverse tribal communities across 14 states are served. Since 2010, a total of 25 

tribal and American Indian or Alaska Native programs across 14 states received 

funding. These programs are located in many different settings, ranging from remote 

Alaskan villages to the rural Midwest and to major urban areas of the Southwest. 

Some serve a single tribe, while others serve multiple tribal communities or consortia 

of tribes. The Tribal Home Visiting Program currently reaches 15 rural grantees, three 

urban grantees, and seven grantees with a mix of rural and urban settings. 

Some of the most vulnerable AIAN children and families are served. The 

MIECHV legislation prioritizes program services for vulnerable families in 

at-risk communities. Priority populations experiencing multiple challenges, 

such as substance abuse, poverty, and a history of child abuse or neglect, were 

successfully identified and served. Seventy-one percent of participants had 

a family income at or below federal poverty guidelines (at or below $11,670 

for an individual or $23,850 for a family of four in 2014). In 2014, many adult 

participants were under 25 years old (43 percent), unemployed (59 percent), 

or without a bachelor’s degree (96 percent). A majority of child participants 

(78 percent) were under three years old. Eighty-five percent of children and 78 

percent of adults were American Indian or Alaska Native.3 

Funds expand the reach of home visiting services in tribal communities. The 

Tribal Home Visiting Program is funded at escalating amounts over five years. As 

expected, grantees had successive increases in program reach and service capacity: 

3

 Individual grantees had the authority to determine service eligibility, and some programs chose to serve families in 

their service area regardless of their AIAN status. 
  

 

8 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

•	 In fiscal year (FY) 2014, 870 families were enrolled, over five times the number 

of families enrolled in 2012 (Figure 1-1). 

•	 A total of 1,523 families were enrolled. This total includes 169 families in 2012, 

484 in 2013, and 870 in 2014. 

•	 Vulnerable families were provided with nearly 20,000 home visits over three 

years (Figure 1-2). 

Figure 1-1. Growth in Participants Figure 1-2. Growth in Home Visits 

Grantees Developed Expansive Capacities to Implement and

Evaluate Home Visiting in Tribal Communities 

Home visiting models were adapted and enhanced for local implementation. 

To meet the needs of local communities, adaptations to existing home visiting 

models, sometimes with the help of the model developers, were developed 

and implemented. Some adaptations include allowing flexibility in home visit 

schedules and locations and incorporating tribal languages and traditional 

teachings into curriculum content. 

Program and community capacities were developed to serve families and young 

children. The Tribal Home Visiting Program is designed as a systems-building 

initiative. Program activities promoted collaboration and coordination to provide 

effective services to meet family needs. The Tribal Early Learning Initiative, for 

example, is a partnership between ACF and four tribal grantees that are collaborating 

across their home visiting, child care, and Head Start/Early Head Start programs. 

Many beneficial coalitions and initiatives were also built to strengthen broader 

early childhood systems in communities. Additionally, in developing performance 

measurement plans, the capacity around data collection and program performance 

was enhanced and would benefit the communities beyond the life of the grants. 

The evidence base for home visiting services with AIAN populations is being 

expanded and strengthened. Rigorous, locally designed evaluations are currently 

being implemented and will expand and strengthen the limited evidence base on 

the use of home visiting with AIAN populations. Given the known intergenerational 
EXECUTIVE SUMMARY 9 

and long-term consequences of historical and ongoing trauma in 

AIAN communities, such as forced relocation and discrimination, 

improving this body of evidence will be invaluable in reducing 

disparities in access to high-quality health care and early education 

services. Through a collaborative process involving program 

leadership and community input, rigorous experimental designs 

are being used to evaluate the efficacy of home visiting services 

on multiple family and child outcomes. Results of these studies 

are expected in spring 2017. The impact of culturally enhanced 

or adapted program models using rigorous, locally designed 

evaluations is also being evaluated. Evaluation results from the 

first two cohorts of tribal grantees are expected to be available in 

spring 2017, following the last year of grant implementation. 

Cohort 1 Grantees Demonstrated Improvement

in Key Determinants of Positive Child and Family

Outcomes 

Impressive gains in program performance across the six 

legislatively mandated benchmark areas (Figure 1-3). A majority of the 13 Cohort 

1 grantees (77 percent, n = 10) demonstrated overall program improvement in the 

three-year period. Overall program improvement is defined as improvement in at 

least four of the six benchmark areas.4

 For additional information on program improvement, see Appendix A. 

 Highlights of program improvements in the 

individual benchmark areas are provided on the following pages. 

Figure 1-3. Percentage and Number of Grantees Improved Overall and in Individual 

Benchmark Areas (N = 13) 

 

 

 

 

 

4
 

10 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Maternal and Newborn Health
 

•	 Promotion of prenatal health care services to ensure positive birth 

outcomes. A majority of grantees (77 percent, n = 10) improved performance 

measures for prenatal care. During FY 2012 through FY 2014, 89 percent of 

participants from seven grantees with similar performance measures initiated 

prenatal care by their first or second trimester. 

•	 Increased screening rates for maternal depressive symptoms. Most grantees 

(77 percent, n = 10) improved screening rates for maternal depression. During 

FY 2012 through FY 2014, 12 grantees with similar performance measures 

screened 71 percent of participants for maternal depression. 

•	 Increased initiation and duration of breastfeeding, a practice linked to 

positive child outcomes. Most grantees (62 percent, n = 8) improved on 

measures of initiation and duration of breastfeeding. 

Reduced Child Injuries; Child Abuse, Neglect, or Maltreatment; 

and Reduction in Emergency Department Visits 

•	 Reduced rates of substantiated reports and first-time victims of child 

maltreatment. Almost all grantees (92 percent, n = 12) reduced rates of 

substantiated reports and first-time victims of child maltreatment. During 

FY 2012 through FY 2014, the average rate of first-time victims of child 

maltreatment across grantees was 10 percent. 

•	 Decreased child injuries requiring medical treatment. A majority of 

grantees (77 percent, n = 10) reduced rates of child injuries requiring medical 

treatment. During FY 2012 through FY 2014, the average rate of child injuries 

requiring medical treatment among eight grantees with similar performance 

measures was three percent. 

School Readiness and Achievement 

•	 Improved parent well-being and reduced parenting stress to support 

positive parenting behaviors and healthy parent-child relationships that 

in turn predict school readiness and academic achievement (Adi-Japha & 

Klein, 2009; Thompson, 2008; Adirim & Supplee, 2013). Almost all grantees 

(92 percent, n = 12) improved on measures of parent emotional well-being or 

parenting stress. 

•	 Improved rates of screenings to identify developmental delays and link 

families to necessary resources and supports. During FY 2012 through FY 

2014, nine grantees with similar performance measures screened an average 

of 51 percent of eligible children across developmental domains. This rate is 
EXECUTIVE SUMMARY 11

well above the national average of 31 percent for child screenings in 2011 and 

2012 (Child and Adolescent Health Measurement Initiative, no date).

Reduced Crime or Domestic Violence

• Increased screening rates for domestic violence and increased support for 

families when domestic violence is present. Fifty-four percent of grantees 

improved on their screening for domestic violence, while 69 percent saw 

increases in safety plan completion for families experiencing domestic 

violence. 

Family Economic Self-Sufficiency

• Increased number of adults and children with health insurance. Almost all 

grantees (85 percent, n = 11) saw increased rates of adults and children with 

health insurance. During FY 2012 through FY 2014, a majority of mothers and 

children (86 percent) from six grantees with similar performance measures 

had health insurance within 12 months of enrollment. 

Coordination and Referrals with Other Community Resources and Supports

• Improved collaboration and information sharing with other community 

agencies. Almost all grantees (92 percent, n = 12) improved information sharing 

and collaborations with other community agencies. 

In many cases, program data offers a limited view of the 

Tribal Home Visiting Program. The details of individual 

family successes—from a young mother enrolling in 

school and finding stable housing to early identification 

of a child’s learning disability—can be lost when 

reporting on families overall. Additionally, the Tribal 

Home Visiting Program serves only a small fraction of 

the families in Indian Country, despite the increased 

reach. Individuals from over 50 tribal communities are 

being served, but these communities represent a small 

percentage of the 566 federally recognized tribal nations 

and the 37 Urban Indian Centers, tribal consortia, and 

other tribal organizations across the nation (Westat, 

2014). The 2,697 adults and children served represents 

less than one percent of the 5.2 million individuals who 

identify themselves as American Indian and Alaska 
 

12 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Native, indicating a continued need for program expansion and sustained funding 

(Norris et al., 2012). 

SUMMARY AND RECOMMENDATIONS 

After four years of implementation, ACF recognizes the opportunity to strengthen 

the Tribal Home Visiting program and build on the solid foundation already 

established. Going forward, ACF will maintain high expectations for Tribal 

MIECHV grantees and support their success through continued efforts to develop 

and enhance early childhood systems in tribal communities, improvements to the 

performance measurement and continuous quality improvement system in close 

communication with tribal grantees, and promotion of a learning agenda to build 

knowledge of effective home visiting in tribal communities. 

As exemplified by the Tribal Early Learning Initiative, and demonstrated by the tribal 

home visiting grantees, children and families are served best when collaborative 

relationships, partnerships, and referral networks are established for a solid early 

childhood system infrastructure. ACF will continue to emphasize this priority of 

early childhood systems building as the Tribal Home Visiting program continues. 

As demonstrated in this report, the benchmarks process helped to build the 

capacity of grantees for monitoring the success of their programs. ACF will 

continue to emphasize efforts to support grantees in using performance 

measurement data to improve programs through modifications to the benchmark 

requirement that facilitate use of the data for continuous quality improvement 

and other priorities. These changes to the benchmarks requirement will be made 

in close communication with grantees, following expert guidance. 

Finally, given the expectations for rigorous evaluation of home visiting in tribal 

communities, the Tribal Home Visiting program has helped to build local and 

tribal capacity for evaluation. ACF will continue to foster local grantee efforts 

to understand their own home visiting programs while supporting efforts to 

generate knowledge to inform the broader field of implementation science 

around adaptation and other important topics. 
   2
 LEGISLATIVE
 LANGUAGE 

On March 23, 2010, President Obama signed the Patient Protection and 

Affordable Care Act of 2010 with a provision authorizing $1.5 billion in funding 

over five years for the Maternal, Infant, and Early Childhood Home Visiting 

Program (MIECHV). Three percent of these funds were set aside for grants to 

eligible Indian tribes, consortia of tribes, tribal organizations, and urban Indian 

organizations. The portion of MIECHV dedicated to these entities is hereafter 

referred to as the “Tribal Home Visiting Program.” 

The following report is provided to Congress as outlined in Section 511 of the Social 

Security Act (Sec. 511, SSA). The legislation stipulates that, no later than December 

31, 2015, a report to Congress must be submitted on programs conducted under 

the MIECHV program, including the Tribal Home Visiting Program. This report 

focuses primarily on the efforts of Tribal Home Visiting grantees. A separate report 

provides more details on the activities of State Home Visiting grantees. 

The report shall contain information from three areas: 

1.	 Extent to which eligible entities receiving grants under this section 

demonstrated improvements in each of the areas specified in the legislation 

2.	 Technical assistance (TA) provided to grantees, including the type of assistance 

provided 

3.	 Recommendations for such legislative or administrative action as the 

Secretary determines appropriate 

13 
This page is intentionally blank. 
   3 PURPOSE AND
 ORGANIZATION
 OF THE REPORT 

The following explains the purpose of this report: 

1.	 Describe the Tribal Home Visiting Program, grantees, and family and 

community contexts that influence implementation of the program 

2.	 Highlight the expanded reach and availability of home visiting services in tribal 

communities as a function of the Tribal Home Visiting Program 

3.	 Tell the story of program implementation across funding years, highlighting 

successes and areas of improvement 

4.	 Describe technical assistance (TA) and systems of support provided to grantees 

5.	 Summarize grantee performance measurement and grantee performance in 

legislatively mandated benchmark areas 

6.	 Suggest recommendations for improving program reach, supports, and 

requirements 

There are a total of six more chapters. Chapter 4 provides background on the 

influence of early childhood on healthy development and later-life outcomes and 

the critical role of home visiting in supporting at-risk families with young children. 

It also describes the context of home visiting in tribal settings. Chapter 5 gives 

an overview of program goals, funding, and activities. Chapter 6 summarizes 

the work of the 25 grantees, with special attention given to each of their unique 

communities and programs. The extensive support provided to grantees by the 

developers of home visiting models and two TA centers is described in Chapter 7. 

The next two chapters highlight grantee data describing families served (Chapter 

8) and grantee program performance (Chapter 9). Chapter 10 concludes with a 

15 
16 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

LESSONS FROM THE FIELD 

Throughout the report, you will see text boxes with LESSONS FROM THE FIELD, 

vignettes taken from informal group interviews with Cohort 1 grantees. These vignettes 

provide context to better understand findings from grantees’ perspectives and highlight 

achievements not captured in benchmark data. 

summary of findings, lessons learned, and recommendations for improvements 

to the program. The content of this report reflects data collected from several 

sources:5 

 Appendix A provides a more in depth description of Tribal Home Visiting data requirements and limitations. 

•	 Demographic, service utilization, and performance measurement data 

submitted by the grantees to the Administration for Children and Families 

(ACF). Grantees submit data through the Discretionary Grant Information 

System, the first national reporting system of home visiting services provided 

to American Indian and Alaska Native (AIAN) populations. 

•	 Informal group interviews with grantees on their experiences with program 

implementation and performance measurement.6 

 Informal group interviews were conducted with all 13 grantees funded in Cohort 1 of the Tribal Home Visiting 

Program in spring 2015. These group interviews included grantee home visitors, program administrators 

(Coordinators and Directors), and evaluators. 

•	 Existing documents and reports on the Tribal Home Visiting Program and 

relevant published literature. 

5

6
   4 BACKGROUND
 

A STRONG START: THE SCIENCE 

OF EARLY CHILDHOOD 

Experiences in the first five years of life, a period of tremendous growth and 

development, set the stage for long-term developmental outcomes and wellbeing (Shonkoff & Garner, 2012; Adirim & Supplee, 2013; National Research 

Council & Institute of Medicine, 2000). This early phase of life ideally includes 

relationships with responsive and supportive caregivers, who serve as children’s 

first teachers, and exposure to high-quality learning experiences. A growing body 

of brain research points to these early years as a critical period for establishing 

positive parent–child relationships that result in healthy brain development and 

learning trajectories (Shonkoff & Garner, 2012; Bagot & Meaney, 2010; National 

Research Council & Institute of Medicine, 2000). 

Children with attentive and supportive caregivers have better health outcomes 

and physical development, greater cognitive skills, and greater social-emotional 

competence and are better prepared to benefit from formal school experiences 

than children with less supportive caregivers (Adi-Japha & Klein, 2009; Thompson, 

2008; Adirim & Supplee, 2013). Longitudinal studies also demonstrate that highquality early learning experiences result in higher academic gains, greater adult 

earnings, and less crime (Lawrence, 1993; Reynolds et al., 2001; Farran, 2000; 

Schweinhart et al., 2004). 

Early childhood interventions yield a high return on investment, both in human 

capital gains and economic returns (Doyle et al., 2009). A review of benefit-cost 

analysis studies showed a $1.26 to $17.07 cost saving for every dollar invested 

17 
 

18 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

in early childhood interventions (Karoly et al., 2005). Moreover, in one home 

visiting study, benefits were greater for higher-risk participants ($5.70 for every 

dollar invested) compared with lower-risk participants ($1.26 for every dollar 

invested) (Karoly et al., 2005). These findings suggest that (1) early childhood 

interventions have the potential to improve outcomes for children and families 

and yield great cost savings and (2) the programs serving higher-risk families yield 

the greatest benefits. 

SUPPORTING FAMILIES AND YOUNG CHILDREN: 

THE ROLE OF HOME VISITING 

Supporting families with young children is an essential component of a 

comprehensive system of care for our nation’s children (Daro, 2009; Garner, 

2013). Early and long-term development is closely tied to family functioning, 

early experiences with caregivers, and parental structuring of early learning 

environments (Shonkoff & Garner, 2012; World Health Organization, 2004). 

Adverse childhood experiences, from child abuse and neglect to family poverty 

and stress, predict a host of negative outcomes (Felitti et al., 1998; Duncan 

et al., 2010; Shonkoff & Garner, 2012). In helping families navigate the many 

demographic, parental, and family stressors they face, interventions support the 

development of adaptive skills and nurturing relationships that buffer against 

stress and prevent adverse childhood experiences (Garner, 2013). 

Home visiting programs use home visits as a primary delivery strategy to support 

pregnant women, expectant fathers, and parents and caregivers of children from 

birth to kindergarten entry. Home visiting programs help expectant families and 

families with young children provide stimulating early learning environments, 

nurturing relationships, and healthy family functioning for their children. These 

factors, in turn, have profound effects on children’s physical, social-emotional, 

and cognitive development. Services are provided by trained professionals, such 

as social workers, nurses, and parent educators. These trained professionals 

work with families to establish positive parenting practices and parent–child 

relationships while also addressing immediate individual family needs. As a 

result, they mitigate the poor developmental outcomes associated with family 

poverty and stress and provide vulnerable children and families with critical and 

lifelong protective factors (Lugo-Gil & Tamis-LeMonda, 2008; Pew Center on the 

States, 2011). 

Home visiting improves a wide range of short- and long-term child and family 

outcomes, including positive cognitive and language outcomes for children, 

efficient family use of health services, positive changes in parenting attitudes 
BACKGROUND 19 

and behaviors, and reduced child maltreatment and abuse (Daro, 2006; Wagner 

et al., 2001; Raikes et al., 2006; Guterman, 2001; Home Visiting Evaluation of 

Evidence [HomVEE], 2014). Parent education and employment outcomes are also 

improved, and family economic self-sufficiency is increased (HomVEE, 2014). As 

a result, home visiting is a cost-effective prevention strategy, providing positive 

returns on investment through eventual reductions in health and education costs 

(Pew Center on the States, 2011). 

As part of the Obama administration’s early childhood initiative and continuum of 

high-quality early childhood services, the Tribal Home Visiting Program expands 

access to critical home visiting support services in tribal communities. Its aim is 

to expand the evidence base for home visiting for AIAN populations, supporting 

the development of a comprehensive system of care for our nation’s Native 

children. 

HOME VISITING IN TRIBAL COMMUNITIES 

Tribal Communities Experience Unique Challenges 

Although tribal communities are diverse, they share a distinct set of 

challenges. Compared with the general U.S. population, AIAN communities 

disproportionately experience negative health outcomes (Centers for Disease 

Control and Prevention [CDC], 2013). Health disparities may result from 

limited resources and access to services, loss of culture, unemployment, 

pervasive drug and alcohol abuse, poverty, and low educational attainment 

(CDC, 2011; King et al., 2009; Duran & Duran, 1995). In addition, health 

disparities within tribal communities are attributed to historical trauma—the 

collective emotional and psychological suffering endured by a massive group, 

manifesting throughout the life span of group members and passed down 

through generations (Brave Heart et al., 2011). Sources of historical trauma 

for indigenous peoples include colonization; prohibition of language, spiritual 

practices, and ceremonies; forced assimilation and removal of children to 

boarding schools; and other traumatic losses (Fisher & Ball, 2002; Brave 

Heart, 1998). 

Tribal Communities Possess Assets and Strengths 

While American Indian communities face an array of unique challenges, they 

also possess many undeniable community assets and strengths to support 

the healthy development of families and children. Community strengths 

may include cultural identity and traditions, intergenerational knowledge, 
 

20 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

community ties and connectedness, language, spiritual ceremonies, and 

traditional childrearing practices (ACF, 2012; Whitbeck, 2006; Fisher & Ball, 

2002; Krech, 2002; Hodge et al., 2009). The American Indian family, both 

immediate and extended, can provide children with a strong foundation for 

exploring individual and community identity, learning cultural teachings, and 

better understanding their roles within the family and the community as 

a whole. Tribal communities traditionally create “kin networks” to ensure 

that children receive support from birth by a large extended family. Naming 

ceremonies and other early-life activities serve to solidify the roles of extended 

family members in sharing these teachings and building the support for families 

and children as they grow and develop. 

Home-Based Support for Families through Traditional

Cultural Practices 

Red Horse and colleagues (1978) suggest that family-focused human services 

interventions in tribal communities, as currently understood, are not independent 

of daily life for those with the greatest need but are inherently integrated as 

typical traditional cultural practices. Support networks, comprising of relatives 

and other community members, traditionally provide young families with 

informal visits to their homes to offer food, assistance, and well wishes (Red 

Horse, 1997; Red Horse et al., 1978). Research with urban Indian families has 

found that they are more likely than White families to receive this type of kin 

support (Limb et al., 2012). Today, many American Indians perceive informal 

services such as these to be more effective than formal services (Walls et al., 

2006). While these informal supportive visits have continued in many tribal 

communities, many American Indian people may associate the formal “home 

visit” with different purposes, such as child welfare investigations. A visit from 

a county or state child protection worker could result in removal of children, 

frequently due to misunderstandings about childrearing practices rather than 

maltreatment (Unger, 1977; Mannes, 1995). 

Formalized Home Visiting as a New Strategy in Tribal Communities 

More recently, service systems have sought to provide supportive 

interventions within the home setting in tribal communities. Lay community 

health workers, charged with making in-home visits, are often used to support 

preventive services for American Indian populations. They have a proven 

ability to apply historical and cultural knowledge with formal health training 

to mobilize efforts across community resources (Satterfield et al., 2002). 

Child welfare visits have shifted to a model promoting family preservation and 
 

BACKGROUND 21 

support. In their report The Context and Meaning of Family Strengthening 

in Indian America, Besaw and colleagues (2004) contend that health care, 

human services, and educational programs driven, designed, and controlled 

by tribal communities show the best promise for effectiveness in Indian 

Country. In many ways, the home visiting services provided through the Tribal 

Home Visiting Program demonstrate this shift to formalized but supportive 

home-based programming. 

An Opportunity to Support and Learn from Tribal Communities 

While strong evidence shows that home visiting is an effective intervention 

strategy that fits within some cultural practices as described above, less is 

known about the effectiveness of these services in tribal settings. In 2009, 

prior to launching the Home Visiting Program, the ACF Office of Planning, 

Research and Evaluation began a systematic review of home visiting research. 

The review included an assessment of the current research evidence 

supporting the effectiveness of various home visiting program models 

(HomVEE, 2014). Through a parallel review process, the first Tribal HomVEE 

review determined that no models met the HHS criteria for evidence of 

effectiveness with tribal communities7

 (Del Grosso et al., 2011). Therefore, 

models that had evidence of effectiveness with other populations and that 

were deemed evidence-based by the original HomVEE review are considered 

promising approaches rather than evidence-based approaches when they are 

applied to tribal communities. Despite this distinction, the term “evidencebased” is used throughout the report to describe those home visiting models 

used by tribal grantees that have evidence of effectiveness, albeit with other 

populations. 

Evidence-based home visiting services—which may include prescriptive 

strategies, fidelity monitoring, and data collection—remain a relatively 

new approach in many tribal settings. Tribal communities with experience 

implementing evidence-based programs have advocated strongly to ensure 

that these programs can be adapted or enhanced to fit specific community 

context. Examples of cultural enhancements to home visiting program models 

include cultural activities and events, storytelling, and integrated elements of 

traditional language. Research suggests that family-centered interventions 

rooted in indigenous cultural values and practices are most likely to be 

7

 Since the initial Tribal HomVEE review, the Family Spirit home visiting model has been determined to meet criteria 

for effectiveness (Mraz Esposito et al., 2014). 
22 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

implemented with fidelity and sustained over time in AIAN communities 

(Fisher & Ball, 2002). 

With the integration of community-based knowledge, home visiting practices 

have the potential to align well with family support practices in tribal settings. 

Because evidence-based intervention remains a new strategy for many tribal 

communities, the Tribal Home Visiting Program provides a unique opportunity to 

support and learn as they implement these innovative services. 
 

 

   5
 OVERVIEW OF THE TRIBAL
 HOME VISITING PROGRAM 

DESCRIPTION OF THE PROGRAM 

On March 23, 2010, President Obama signed the Patient Protection and Affordable 

Care Act of 2010. In authorizing the creation of Maternal, Infant, and Early 

Childhood Home Visiting Program (MIECHV, the Federal Home Visiting Program), 

the Affordable Care Act greatly expanded federal funding for voluntary, evidencebased home visiting programs for expectant families and families with young 

children up to age five in at-risk communities (Sec. 511, SSA). MIECHV provides 

an unprecedented opportunity for collaboration at the federal, state, tribal, and 

community levels to improve health and developmental outcomes for at-risk 

children. Three percent of these funds were set aside for grants to eligible Indian 

tribes, consortia of tribes, tribal organizations, and urban Indian organizations, 

awarded by the Secretary of the Department of Health and Human Services (HHS). 

The Tribal Home Visiting Program is authorized by Section 511(h)(2)(A) of Title V of 

the Social Security Act, as amended by the Medicare Access and Children’s Health 

Insurance Program (CHIP) Reauthorization Act of 2015 (Public Law (Pub.L.) 114-10). 

Legislation dictates that the requirements for tribal grants be consistent with those 

of MIECHV grants awarded to states “to the extent practicable,” including conducting 

a needs assessment and establishing benchmarks. 

HHS has historically allocated funding for the Tribal Home Visiting Program as 

follows: 

• FY 2010, up to $3 million 

• FY 2011, $7.5 million 

• FY 2012, $10.5 million 

23 
24 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

•	 FY 2013, $12 million 

•	 FY 2014, $12 million 

•	 FY 2015, $12 million 

The goals and requirements of the Tribal Home Visiting Program mirror those 

of the MIECHV grants awarded to states. The goals of the Tribal Home Visiting 

Program are the following (HHS, ACF, Office of Child Care, no date): 

1.	 Support the development of happy, healthy, and successful American 

Indian and Alaska Native children and families through a coordinated 

home visiting strategy that addresses critical maternal and child health, 

development, early learning, family support, and child abuse and neglect 

prevention needs 

2.	 Implement high-quality, culturally relevant, evidence-based home visiting 

programs in AIAN communities 

3.	 Expand the evidence base around home visiting interventions within AIAN 

populations 

4.	 Support and strengthen cooperation and promote linkages among various 

early childhood programs, resulting in coordinated and comprehensive early 

childhood systems 

Per the legislation, Tribal Home Visiting Program grantees prioritize services to 

the following AIAN populations: 

•	 Families in at-risk communities identified through a needs assessment 

•	 Low-income families 

•	 Pregnant women under age 21 

•	 Families with a history of child abuse or neglect 

•	 Families with a history of substance abuse 

•	 Families that have users of tobacco in the home 

•	 Families with children with low student achievement 

•	 Families with children with developmental delays or disabilities 

•	 Families with individuals who are serving or have served in the Armed Forces, 

including those with multiple deployments 

The Administration for Children and Families, through the Office of the Deputy 

Assistant Secretary for Early Childhood Development and the Office for Child 

Care, oversees the Tribal Home Visiting Program in collaboration with the 
OVERVIEW OF THE TRIBAL HOME VISITING PROGRAM 25 

Health Resources and Services Administration (HRSA). ACF awards five-year8 

cooperative agreements through a competitive process. They are awarded with 

the anticipation that the federal government will be substantially involved and 

will provide training and technical assistance to grantees throughout the project 

period (ACF, 2012). This involvement aims to build the capacity of grantees to 

complete needs assessments, planning, benchmark data collection, and rigorous 

evaluation activities. The goal is to ensure effective program implementation, 

with fidelity to evidence-based models when appropriate. 

There is a great need to expand and strengthen the evidence base for home 

visiting programs targeted to tribal populations and communities. As such, the 

priorities are to provide high-quality, culturally relevant, evidence-based services 

and draw from implementation science to build a knowledge base around 

home visiting with AIAN populations. The Tribal Home Visiting Program also 

emphasizes the fit between the selected home visiting model and community 

needs, priorities, capacities, culture, and context (HHS, ACF, Office of Child Care, 

2014). As a federal investment, the program incorporates a distinctive approach, 

prioritizing tribal community decision-making on grant implementation and 

focusing on community capacity building. The intention is that the program 

will result in a coordinated system of early childhood home visiting in tribal 

communities and provide infrastructure and supports to ensure high-quality, 

evidence-based practice (ACF, 2012). 

Since 2010, a total of 25 grantees have received federal grants through the 

Tribal Home Visiting Program to develop, implement, and evaluate home visiting 

programs in AIAN communities. Thirteen cooperative agreements were awarded 

in FY 2010, six were awarded in FY 2011, and another six were awarded in FY 

2012. The grantees are diverse in size, location, organizational structure, capacity, 

and culture. They are located in many different settings, ranging from remote 

Alaska to the rural Midwest and to major Southwest and west coast urban areas. 

A number of grantees are tribal agencies located on reservations, while others 

represent tribal communities without reservation land. Some serve a single 

tribe, while others serve multiple tribal communities or represent a consortium 

of tribes (HHS, ACF, Office of Child Care, 2014). Several grantees are urban Indian 

organizations that serve a diverse urban Indian population representing hundreds 

of tribal affiliations. 

8

 A short-term reauthorization of funding in 2014 made it possible to add an additional grant year to programs 

entering their fifth year of funding (Cohort 1 grantees), making them six-year grants. 
 

26 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

ACTIVITIES SUPPORTED BY GRANT FUNDS 

To ensure Tribal Home Visiting Program grantees achieve their goals, the 

cooperative agreements involve several of the following distinct activities: 

•	 Conducting a needs and readiness assessment of the tribal community(ies) 

•	 Engaging in collaborative planning efforts to address identified needs by 

developing capacity and infrastructure 

•	 Providing high-quality, evidence-based home visiting services to pregnant 

women, expectant fathers, parents, and primary caregivers of young children 

from birth to kindergarten entry 

•	 Developing a data system and mechanism to measure, track, and report on 

progress toward meeting legislatively mandated benchmarks 

•	 Conducting rigorous local program evaluation activities 

Using an implementation science–based approach, ACF staged these activities 

in a way that optimized the potential for grantees to put the right program into 

practice with adequate supports and infrastructure. 

Needs and Readiness Assessments 

During the first year of funding, grantees conducted a needs and readiness 

assessment that informed model selection and program planning. Needs 

assessments were used to do the following: 

WHAT IS IMPLEMENTATION SCIENCE? 

Implementation science is the systematic study of the activities involved in putting 

a particular program, such as an evidence-based program, into practice. 

The science suggests that program implementation is a process with various 

stages, such as exploration, installation, and initial and full implementation. 

These stages are dynamic and nonlinear, meaning programs can move back and 

forth between the stages throughout the process. Implementation science also 

shows that various drivers, including facilitators and barriers, create opportunities 

and limitations to change. 

Using an implementation science lens allows for a thoughtful and data-driven 

consideration of interventions applied in real-world contexts. 
OVERVIEW OF THE TRIBAL HOME VISITING PROGRAM 27 

1.	 Identify and characterize the at-risk community(ies) by providing data on the 

health and well-being of individuals and families in the community, as well as 

information on community strengths, risks, and protective factors 

2.	 Identify the quality and capacity of existing programs or initiatives for early 

childhood home visiting in the target community(ies) 

3.	 Assess community(ies) capacity for providing substance abuse treatment and 

counseling services to individuals and families who need them 

4.	 Assess community(ies) capacity to implement and integrate home visiting 

services into an early childhood system, including an assessment of existing or 

ongoing efforts or resources to develop a coordinated early childhood system 

at the community level 

Comprehensive Implementation Planning 

Through needs and readiness assessments (focus groups, interviews, 

community meetings, informal conversations, and surveys), grantees engaged 

stakeholders to design an implementation plan that would meet the needs 

of their communities. Upon completion, each tribal grantee engaged in 

collaborative planning efforts to develop a comprehensive implementation 

plan. Each plan includes a description of: (1) the community needs 

assessment used to identify the targeted community(ies); (2) a description of 

the home visiting program goals and objectives that aligned with the needs of 

the targeted communities; (3) the home visiting model(s) proposed to meet 

identified needs; (4) plans for effective implementation of the home visiting 

program, including anticipated technical assistance needs and continuous 

quality improvement (CQI) strategies; (5) a plan for meeting legislatively 

mandated benchmark requirements; (6) a rigorous evaluation plan; (7) a plan 

for the administration of the home visiting program; and (8) a budget and 

budget justification. 

The flexibility, through legislation, to align requirements of the tribal program 

with the state program, to the greatest extent possible, allowed ACF to 

require grantees to choose a home visiting model that had been established 

as a promising approach for use in tribal communities and responded to 

the needs of their communities as identified through the assessment. In 

addition to outlining how the chosen model would address community 

needs, grantees described how the community participated in the selection 

and implementation of the home visiting model. Promising approaches are 

defined by the following (ACF, 2012): 
28 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

1.	 A model studied by the Tribal HomVEE review but found not to meet criteria 

for evidence of effectiveness 

2.	 A model studied by the larger HomVEE review and adapted to meet the needs 

of the tribal community 

3.	 A model that was not studied by either the tribal or the larger HomVEE review 

and adapted to meet the needs of the tribal community 

4.	 A model developed by the grantee to meet community needs, in partnership 

with a national organization or institution of higher education, for the 

purposes of the Tribal Home Visiting Program 

5.	 An adapted or modified version of an approved model for the State Home 

Visiting Program that includes significant alterations to core components 

Providing High-Quality Evidence-Based Home Visiting Services 

Once a comprehensive implementation plan was completed, home visiting 

services were provided within the communities. Grantees partnered with the 

developers of the models to design and implement program adaptations or 

enhancements. They aimed to address unique community needs, interests, and 

contexts while maintaining fidelity to the model. Many of these enhancements 

incorporate local tribal culture into home visiting curricula and group socialization 

activities. 

Benchmarks 

The legislation requires grantees to establish quantifiable, measurable 

performance measures to demonstrate program improvements in six benchmark 

areas: 

1.	 Maternal and newborn health 

2.	 Child injuries; child abuse, neglect, or maltreatment; and reduction of 

emergency department visits 

3.	 School readiness and achievement 

4.	 Crime or domestic violence 

5.	 Family economic self-sufficiency 

6.	 Coordination and referrals for other community resources and supports 

Grantees developed and implemented individualized performance 

measurement plans for monitoring program performance on these 

benchmarks. As part of this process, data collection and management 
OVERVIEW OF THE TRIBAL HOME VISITING PROGRAM 29 

protocols, analysis plans, and data systems capable of housing and linking 

data across programs were also developed. 

Rigorous Evaluation 

In addition to monitoring performance on benchmarks, grantees are required 

to develop a plan for conducting a rigorous evaluation. These evaluations 

are intended to strengthen the evidence base for home visiting models and 

enhancements and contribute to the field. Evaluations examine the impact of the 

intervention on a targeted set of outcomes or the adoption, implementation, and 

enhancement of programs. Within the Tribal Home Visiting Program, evaluation 

rigor involves the principles stated below (James Bell Associates, 2012). 

•	 Credibility: Is what is intended to be evaluated actually being evaluated, 

and does the proposed data collection and analysis appropriately answer the 

research questions of interest? For example, if the research question focuses 

on efficacy, an appropriate comparison group must be used. 

•	 Applicability: Results can be generalized beyond this project, and the reader 

can believe the results accurately represent a population or context. For 

example, communities included in the evaluation must be appropriately 

representative of communities that qualify for home visiting grant funds. 

•	 Consistency: The process and method are articulated in advance and 

closely followed. Evaluation plans should include specific measures, data 

collection procedures, and analysis plans. Consistency includes being 

consistent in data collection to reduce error and pre-specifying analysis 

plans to reduce bias. 

•	 Neutrality: Results are as objective as possible, with an acknowledgement of 

the bias that may be brought to data collection, analysis, and interpretation 

of the results. To this end, the evaluation team must have the necessary 

independence from the project to ensure objectivity, regardless of the 

research question. 

Tribal Home Visiting Program grantees developed rigorous and culturally 

appropriate evaluation plans to examine various questions of interest and to 

contribute to the broader knowledge base on home visiting in tribal communities. 

Some of the outcomes to be evaluated include child development, parental 

stress, cultural connectedness, family retention and engagement, parental 

empowerment, referral completions, and traditional parenting practices. Many 

grantees chose to focus their evaluations on cultural enhancements to the home 

visiting model. Evaluation results from the first two cohorts of tribal grantees 
30 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

are expected to be available in fall 2017, following their last year of grant 

implementation. 

Each of the Tribal Home Visiting Program grantees is unique in locale, 

community and families served, model chosen, and cultural adaptations or 

enhancements incorporated into the model. An overview of grantee locations, 

the home visiting models selected, and individual program descriptions 

(including families served, services provided, and grantee evaluations) are 

included in the following chapter. 
6  DESCRIPTION OF 

THE GRANTEES 

31

The 25 grantees participating in the Tribal Home Visiting Program represent 

diverse communities from across the country. Located in 14 states and six ACF 

regions, these tribal communities vary in size, governance structures, culture, 

and locale (Table 6-1). Although some grantees serve one tribe on a reservation, 

others serve multiple tribes on reservations or in a combination of reservations 

and urban communities. Other grantees represent federally recognized tribes 

that are not reservation based, including Alaska Native Corporations and their 

nonprofit entities. Figure 6-1 illustrates the regional location of grantees across 

the country.

Table 6-1. Grantee Service Population Locale

Locale Number of Grantees

Rural 15

Urban 3

Rural and Urban 7

Home Visiting Models Selected by Grantees

As required, Tribal Home Visiting Program grantees selected models that were 

developed by a national organization or institution of higher education, had 

been in existence for at least three years, and met the needs of the community 

(Department of Health and Human Services, no date). In addition, the models 

include comprehensive program standards that ensure high-quality service 

delivery and continuous quality improvement. Table 6-2 describes each of the six 

selected home visiting models. 
32 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Figure 6-1. Map of Grantee Locations 

Table 6-2. Overview of Selected Home Visiting Models9 

Model Model Description 

Parents as The goals of Parents as Teachers are to provide parents with child development knowledge 

Teachers and parenting support, provide early detection of developmental delays and health issues, 

(PAT) prevent child abuse and neglect, and increase children’s school readiness. The PAT model 

includes one-on-one home visits, monthly group meetings, developmental screenings, and 

a resource network for families. Parent educators conduct the home visits using structured 

visit plans and guided planning tools. Local sites offer at least 12 hour-long home visits 

annually, with more for higher-need families. PAT serves families for at least two years 

between pregnancy and kindergarten entry. Although not a tribally-focused model, PAT has 

been adapted and delivered in more than 100 tribal communities in the United States. More 

than 10,000 American Indian families have been served with the model. 

Family Spirit Family Spirit is designed for Native American mothers and their children. It aims to promote 

mothers’ parenting, coping, and problem-solving skills to address factors such as demographic 

challenges, family-of-origin problems, and personal stressors. The curriculum, which 

incorporates traditional tribal teachings, consists of 63 independent lessons in six domains. 

When the full curriculum is appropriate, Family Spirit recommends initiating the program 

with weekly visits at 28 weeks gestation and tapering to bimonthly visits until the child’s 

third birthday. Paraprofessional health educators conduct the visits, which are typically 45 

to 90 minutes in duration. Family Spirit recommends that health educators come from the 

participating community and have familiarity with tribal culture, traditions, and language. 
DESCRIPTION OF THE GRANTEES 33 

Model Model Description 

Nurse Family The Nurse Family Partnership is designed for first-time, low-income mothers and their 

Partnership children. It includes one-on-one home visits by a trained public health registered nurse. The 

(NFP) visits begin early in the woman’s pregnancy (with program enrollment no later than the 28th 

week of gestation) and conclude when the woman’s child reaches age two. NFP is designed 

to improve (1) prenatal health and outcomes, (2) child health and development, and (3) 

family economic self-sufficiency and/or maternal life-course development. 

SafeCare SafeCare Augmented is an enhancement to SafeCare. It includes motivational interviewing 

Augmented and additional training for home visitors on identifying and responding to imminent 

child maltreatment and risk factors, such as substance abuse and depression. SafeCare 

Augmented was adapted for high-risk, rural communities. The original SafeCare model 

aims to prevent and address factors associated with child abuse and neglect. Eligible 

clients include families with a history of child maltreatment or families at risk for child 

maltreatment. SafeCare typically provides 18 to 22 weeks of training to parents with 

children from birth to age five. During 60- to 90-minute weekly or biweekly home visits, 

trained home visitors conduct baseline and follow-up assessments, observations, and 

trainings with parents. Trainings focus on three modules, each implemented over five 

to seven visits: (1) infant and child health, (2) home safety, and (3) parent–infant and 

parent–child interactions. During the parent trainings, home visitors explain the rationale 

for a particular concept, model the concept, observe the parent practicing the steps, 

and then provide feedback. Home visitors are not required to meet specific educational 

requirements. 

Parent-Child The Parent-Child Assistance Program is an evidence-based home visitation case management 

Assistance model for mothers who abuse alcohol or drugs during pregnancy. Its goals are to help 

Program mothers build healthy families and prevent future births of children exposed prenatally to 

(P-CAP) alcohol and drugs. PCAP’s primary aims are: (1) to assist substance-abusing pregnant and 

parenting mothers in obtaining alcohol and drug treatment, staying in recovery, and resolving 

myriad complex problems related to their substance abuse; (2) to ensure that the children are 

in safe, stable home environments and receiving appropriate health care; (3) to link mothers 

to community resources that will help them build and maintain healthy, independent family 

lives; and (4) to prevent the future births of alcohol- and drug-affected children. 

Home Home Instruction for Parents of Preschool Youngsters aims to promote school readiness 

Instruction and support parents as their children’s first teachers by providing instruction in the home. 

for Parents The program model is designed for parents who lack confidence in their abilities to prepare 

of Preschool their children for school, including parents with past negative school experiences or limited 

Youngsters financial resources. HIPPY offers weekly, hour-long home visits for 30 weeks a year and 

(HIPPY) two-hour monthly or bi-monthly group meetings. HIPPY sites are encouraged to offer the 

three-year program model serving three to five-year olds but can also offer a two-year 

program model. A HIPPY site typically draws the home visiting paraprofessionals from the 

same population that is served. A professional program coordinator at each site oversees 

implementation and supervises the home visitors. 

9

 Summaries for all models were retrieved from the HomVEE Web site (http://homvee.acf.hhs.gov/Models.aspx) with 

the exception of the overview of the Parent-Child Assistance Program. Information on this model was retrieved from 

the University of Washington Web site (http://depts.washington.edu/pcapuw/). 
34 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Each grantee carefully selected the home visiting model that would meet the 

needs of its community and, ultimately, improve the well-being of children and 

families (Table 6-3). About half of the grantees selected Parents as Teachers as 

their primary home visiting model. Other grantees chose Family Spirit, Nurse 

Family Partnership, SafeCare Augmented, Parent-Child Assistance Program, and 

Home Instruction for Parents of Preschool Youngsters. One grantee chose to 

implement two of these models. 

Table 6-3. Home Visiting Models Selected by Grantees 

Model Number of Grantees 

Parents as Teachers (PAT) 13 

Family Spirit 6 

Nurse Family Partnership (NFP) 4 

SafeCare Augmented 1 

Parent-Child Assistance Program (P-CAP) 1 

Home Instruction for Parents of Preschool Youngsters (HIPPY) 1 

Cultural Enhancements and Adaptations to Home Visiting Models 

Most selected home visiting models are not designed for tribal populations; 

as a result many grantees have enhanced or adapted models to fit the culture 

and context of their communities. Examples of adaptations and enhancements 

include hiring culturally competent staff from the community, incorporating 

traditional parenting practices, and involving cultural leaders and elders 

throughout the program development and implementation process. Some 

grantees used grant funds to incorporate the following cultural elements into 

their programs: 

• Cultural activities such as crafts, music, dance, food, and stories 

• Tribal languages, ceremonies, and spiritual practices 

• Topics such as storytelling, cultural values, tribal teachings, and traditions 

Many grantees engaged local advisory groups to oversee the implementation of 

cultural enhancements and invited community elders and traditional specialists 

to participate in and facilitate group meetings. Some also modified their home 

visiting models by serving families with more than one child, using a curriculum 

from other home visiting models or programs, providing leadership development 

opportunities, and tailoring home visitor credentials and caseloads. 
DESCRIPTION OF THE GRANTEES 35 

Populations Targeted by Grantees to Receive Services 

Although target populations varied by grantee, they generally included pregnant 

mothers, primary caregivers, and children from birth to age five. Some grantees 

emphasized subpopulations such as infants, expectant fathers, and children 

receiving care from local health care systems. Grantees designated their own 

priority populations. 

Descriptions of Tribal Home Visiting Program Grantees 

Table 6-4 presents basic information about each of the 25 grantees, listed by 

cohort. The sections that follow detail the families served, services provided, and 

evaluation methods used by each grantee. 

Table 6-4. Grantees by Cohort 

Grantee Program Type State Program Model 

Cohort 1 (FY 2010–2016)
	

Choctaw Nation of Oklahoma Tribal Nation Oklahoma Parents as Teachers 

Fairbanks Native Association, 

Inc. 

Urban Indian 

Organization 

Alaska Parents as Teachers 

Kodiak Area Native Association Tribal Organization Alaska Parents as Teachers 

Lake County Tribal Health 

Consortium, Inc. 

Consortium of 

Indian Tribes 

California Parent-Child 

Assistance Program 

Native American Community 

Health Center, Inc. 

Urban Indian 

Organization 

Arizona Parents as Teachers 

Native American Professional 

Parent Resources, Inc. 

Urban Indian 

Organization 

New Mexico Parents as Teachers 

Northern Arapaho Tribe Tribal Nation Wyoming Parents as Teachers 

Port Gamble S’Klallam Tribe Tribal Nation Washington Nurse Family 

Partnership 

Pueblo of San Felipe Tribal Nation New Mexico Family Spirit 

South Puget Intertribal 

Planning Agency 

Consortium of 

Indian Tribes 

Washington Parents as Teachers 

Southcentral Foundation Tribal Organization Alaska Nurse Family 

Partnership 

White Earth Band of Chippewa 

Indians 

Tribal Nation Minnesota Nurse Family 

Partnership 

Yerington Paiute Tribe Tribal Nation Nevada Parents as Teachers 
 

36 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Grantee Program Type State Program Model 

Cohort 2 (FY 2011–2016) 

Confederated Salish and 

Kootenai Tribes 

Tribal Nation Montana Parents as Teachers 

Eastern Band of Cherokee 

Indians 

Tribal Nation North 

Carolina 

Nurse Family 

Partnership 

Native American Health 

Center, Inc. 

Urban Indian 

Organization 

California Family Spirit 

Riverside-San Bernardino 

County Indian Health, Inc. 

Consortium of 

Indian Tribes 

California Parents as Teachers 

Taos Pueblo Tribal Nation New Mexico Family Spirit and 

Home Instruction for 

Parents of Preschool 

Youngsters 

United Indians of All Tribes 

Foundation 

Urban Indian 

Organization 

Washington Parents as Teachers 

Cohort 3 (FY 2012–2017)
	

Cherokee Nation Tribal Nation Oklahoma Safe Care Augmented 

Choctaw Nation of Oklahoma Tribal Nation Oklahoma Parents as Teachers 

Confederated Tribes of Siletz 

Indians 

Tribal Nation Oregon Family Spirit 

Inter-Tribal Council of 

Michigan, Inc. 

Consortium of 

Indian Tribes 

Michigan Family Spirit 

Red Cliff Band of Lake Superior 

Chippewa 

Tribal Nation Wisconsin Parents as Teachers 

Yellowhawk Tribal Health 

Center 

Tribal Organization Oregon Family Spirit 

COHORT 1 GRANTEES (FY 2010–2016) 

Choctaw Nation of Oklahoma 

The Choctaw Nation of Oklahoma is a non-reservation-based, federally 

recognized, integrated tribe with a tribal service area larger than Delaware, 

Massachusetts, Rhode Island, and the District of Columbia combined. The 

Choctaw Nation serves the second largest tribal area in the lower 48 states, 

spanning more than 11,784 square miles of rural land covered by rugged hills and 
 

 

DESCRIPTION OF THE GRANTEES 37 

valleys. As a non-reservation-based tribe, the Choctaw Nation encompasses the 

Oklahoma Tribal Jurisdiction Area, which spans 10.5 counties. Five counties are 

served by their Cohort 1 home visiting program, Project Chahta Inchukka, and 

the remaining counties are served by a Cohort 3 grant (see the description under 

Cohort 3 Grantees). 

Families 

Served 

Services are provided to high-risk American Indian families with children from 

birth to 24 months. The program enrolls mothers or families with children 

under 12 months. 

Services 

Provided 

Project Chahta Inchukka uses the PAT home visiting model to serve families 

in its community. It also incorporates the National Indian Child Welfare 

Association’s Positive Indian Parenting (PIP) program to provide cultural 

components that speak to the traditions of Native families. 

Evaluation Using a quasi-experimental comparison-group design, the evaluation 

examines parent knowledge of child development, child development 

outcomes, and immunization rates. The evaluation compares the outcomes 

for children and caregivers who receive home visiting with the outcomes for 

similar children and caregivers who do not participate in the program but 

receive pediatric care from the Choctaw Nation Health Care system. 

Fairbanks Native Association 

As an urban Indian organization, the Fairbanks Native Association (FNA) serves 

eligible families located in the Fairbanks North Star Borough (FNSB), the secondlargest population center in the State of Alaska. FNSB spans 7,361 square miles of 

interior Alaska and experiences extreme seasonal temperatures as well as more 

than 22 hours of daylight during the summer solstice. 

Families 

Served 

The FNA Tribal Home Visiting Project serves mothers and their children from 

birth to five years. 

Services 

Provided 

FNA uses the PAT home visiting model with traditional songs, dance, stories, 

and activities integrated into the curriculum to enhance cultural relevance. 

Community elders are involved during group meetings and home visits, and 

staff members are trained in cultural competence to ensure that strategies and 

activities are consistent with the cultural values of the families being served. 

Evaluation The evaluation attempts to determine the impact of the culturally enhanced 

PAT program on attendance, retention, and engagement. The grantee is using 

a quasi-experimental comparison-group design, comparing the outcomes for 

mothers who participate in the new enhanced program with the outcomes 

for mothers who previously participated in the non-enhanced program. 
38 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Kodiak Area Native Association 

The Kodiak Area Native Association (KANA) is a nonprofit tribal organization 

providing health and social services for AIAN families of the Koniag Region 

of Alaska, including Kodiak Island. The federally recognized tribes within the 

Koniag Region include the Native Village of Akhiok, the Native Village of Karluk, 

the Native Village of Larsen Bay, the Village of Old Harbor, the Native Village 

of Ouzinkie, and the Native Village of Port Lions. The Alutiiq (Russian-Aleuts) 

represent the predominant tribal culture in this area. Due to the rural locality of 

this region, the only way of traveling to villages on the island is by boat or plane. 

Families 

Served 

KANA’s Cama’i Tribal Home Visiting Program serves prenatal women, expectant 

fathers, and children from birth to five years living in the Koniag Region. 

Services 

Provided 

KANA adopted the PAT home visiting model and added cultural 

enhancements to the curriculum such as traditional parenting skills, 

storytelling, language, crafts, food, music, and dancing. In addition, 

community elders are used in group connections and advisory roles. 

Evaluation Using a randomized case-control study design with a wait-list control group, 

the evaluation examines parenting behaviors and parent–child relationship 

outcomes for primary female guardians of children who are AIAN and up to 

18 months old and are receiving home visiting services. The evaluation will 

also assess the social and emotional milestones of the child. 

Lake County Tribal Health Consortium, Inc. 

The Lake County Tribal Health Consortium (LCTHC) is a federal, Title I, tribally 

sanctioned organization located about 100 miles north of San Francisco and 

50 miles east of the Pacific Ocean. For 11,800 years, Pomo people have inhabited the 

Pomo ancestral homeland located in Lake County, where seven of the 22 federally 

recognized Pomo tribes currently reside. Members of at least 111 other tribes also 

live in rural Lake County, representing 3.2 percent of the county’s population. 

Families 

Served 

LCTHC’s Gouk-Gumu Xolpelema Partnership with Parents Tribal Home Visiting 

Program provides services to tribal members with children from birth to five 

years living in Lake County, California. 

Services 

Provided 

LCTHC uses the P-CAP home visiting model in combination with the Nurturing 

Parenting curriculum to enhance services and allow for individualized 

parenting support. 

Evaluation The evaluation uses a quasi-experimental comparison-group design to 

examine differences in parenting stress and parenting practice outcomes for 

Native American mothers who participate in Nurturing Parenting versus those 

without P-CAP. 
DESCRIPTION OF THE GRANTEES 39 

Native American Community Health Center, Inc. 

The Native American Community Health Center (NACHCI) is an urban Indian 

organization serving AIAN individuals from more than 30 different tribes residing 

in the Phoenix metropolitan area and the surrounding county. The majority of 

American Indians living in the service area are Navajo. 

Families 

Served 

Services are provided to members of AIAN tribes living throughout the 

Phoenix metropolitan area with children ages birth to five. 

Services 

Provided 

NACHCI uses the PAT home visiting model with culturally enhanced 

group meeting activities. A traditional cultural specialist facilitates group 

activities that incorporate traditional concepts of families and methods of 

raising children. A community advisory board was established to guide the 

development and implementation of cultural enhancement and to advise on 

program implementation. 

Evaluation After the implementation of an enhanced family engagement strategy to 

incorporate cultural enhancements into group meetings, the evaluation 

examines whether family retention improves. The evaluation will compare 

retention rates before implementation of the enhancement with retention 

rates after implementation. 

Native American Professional Parent Resources, Inc. 

Native American Professional Parent Resources (NAPPR) is a community-based, 

nonprofit urban Indian organization serving 10 federally recognized tribes on rural 

reservations in New Mexico and approximately 28,500 urban AIANs living in the 

Albuquerque metropolitan area. NAPPR serves the Pueblo of Acoma, Sandoval 

County, and the To’hajiilee Chapter of Navajo Nation. Service communities are 

diverse in culture and language and include AIAN families from all parts of Indian 

Country. 

Families 

Served 

The NAPPR Tribal Home Visiting Program serves AIAN families with children 

from birth to age five residing within the service communities. 

Services 

Provided 

NAPPR uses the PAT home visiting model with cultural enhancements that 

include integrating traditional stories, language, and knowledge; increasing 

the cultural appropriateness of group meetings; and implementing a Native 

father component. NAPPR has also added a cultural staff-training component. 

Evaluation Using a quasi-experimental comparison-group design, the evaluation examines 

whether Native families who receive the culturally enhanced PAT program have 

greater cultural connectedness outcomes compared with Native families who 

receive the standard PAT program through Early Head Start. 
40 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Northern Arapaho Tribe 

The Northern Arapaho Tribe is located on the Wind River Indian Reservation 

in the Wind River Basin of central Wyoming. Spanning over 2,000,000 acres of 

primarily plains and foothills, the reservation is shared by the Eastern Shoshone 

and the Northern Arapaho Tribes, two very distinct communities and cultures 

with separate but overlapping governmental entities. 

Families 

Served 

The Northern Arapaho Home Visiting Program serves: (1) unmarried 

pregnant teens and teen mothers, (2) women of any age who are pregnant 

and will be first-time mothers, (3) women who are pregnant less than 

six months after delivering an older child, (4) families with a child under 

age three who has been diagnosed with a serious medical condition or 

developmental delay, (5) women who are pregnant and have a medical 

condition that puts an infant at higher risk for maltreatment or neglect (e.g., 

alcoholism, drug abuse, psychiatric illness, chronic illness), and (6) parents 

who have a child or children under the age of three who have regained 

custody after court-ordered removal. 

Services 

Provided 

Home visiting services are provided using the PAT home visiting model 

with cultural enhancements to group meetings that incorporate historical, 

cultural, and traditional values. Elders and traditional people are involved as 

storytellers and guides for some activities. 

Evaluation Using a quasi-experimental comparison-group design, the evaluation 

examines levels of parenting stress in primary caregivers who receive PAT 

home visiting services compared with primary caregivers receiving services 

only through the Special Supplemental Nutrition Program for Women, Infants, 

and Children (WIC) program. 

Port Gamble S’Klallam Tribe 

The Port Gamble S’Klallam Tribe (PGST) lives on a reservation that consists of 

approximately 1,700 acres of forested residential and commercial land held in 

trust by the federal government. There is no private land ownership on the 

reservation. Rural and remote, the reservation is located 1.5 hours by car and 

ferry from Seattle and 45 minutes by car from Bremerton, where the majority of 

services and resources are available. 
DESCRIPTION OF THE GRANTEES 41 

Families 

Served 

The Port Gamble S’Klallam Tribe (PGST) Together for Children Tribal Home 

Visiting Program serves tribal families and their children from before birth to 

age five. 

Services 

Provided 

The program uses NFP for expectant mothers enrolling before week 28 

of their pregnancies and the Brazelton Touchpoints program for pregnant 

mothers enrolling after week 28 of pregnancy or raising a child any age under 

five years. Enhancements to NFP include adapting the program to serve 

families with more than one child and adding culturally relevant photographs 

and S’Klallam-language words to written materials. 

Evaluation Using a single-case design, the evaluation measures changes in parental stress 

(for families receiving NFP), communication in child-rearing and parenting 

practices (for families receiving Touchpoints), and father involvement in 

parenting (for families participating in the tribally sponsored Fatherhood Is 

Sacred program in conjunction with home visiting services). 

Pueblo of San Felipe 

The Pueblo of San Felipe is a federally recognized tribe located in Sandoval 

County, New Mexico. Although it is situated between two urban centers, 

Albuquerque and Santa Fe, the Pueblo is rural and isolated. The Pueblo of San 

Felipe is active with ceremonial dances, pottery, farming, and other traditions. 

Tribal members primarily speak the Keres language (87 percent). 

Families 

Served 

Project Katishtya Eh-wahs Valued Always (KEVA) Tribal Home Visiting Program 

serves women who are first-time mothers, expectant teenage mothers, and 

families who are at risk for substance abuse that include a child up to age five. 

Services 

Provided 

The KEVA Tribal Home Visiting Program provides services using the Family 

Spirit home visiting model along with Circle of Security and a cultural parenting 

curriculum developed in collaboration with elders of the San Felipe Pueblo. The 

curriculum was developed to help teach young parents traditional parenting 

practices and customs that support healthy child development. 

Evaluation Using a qualitative within-person comparison design, the evaluation explores 

the achievement of parenting goals and the relationship between perceived 

goal attainment and the three program components: Family Spirit, Circle of 

Security, and the cultural parenting curriculum. 
 

42 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

South Puget Intertribal Planning Agency 

The South Puget Intertribal Planning Agency (SPIPA) is a tribally chartered nonprofit 

consortium organization that includes five tribes in the State of Washington: 

Chehalis, Nisqually, Shoalwater Bay, Skokomish, and Squaxin Island. The SPIPA 

Healthy Families Project serves six communities; four are rural, and two are urban. 

Families 

Served 

Services are provided to AIAN families, including expectant mothers, teenage 

parents, and parents of children up to age five. 

Services 

Provided 

The Healthy Families Project uses the PAT home visiting model with the PIP 

curriculum and cultural teachings incorporated into home visits. PAT was also 

modified to focus on prevention. Home visitors were hired from within the 

respective communities. 

Evaluation Using a single-case design, the evaluation examines the use of traditional 

Native American parenting practices among participating families. 

Southcentral Foundation 

Southcentral Foundation (SCF) is a nonprofit health care organization of Cook 

Inlet Region, Inc., an Alaska Native regional corporation, with a service area that 

includes the Municipality of Anchorage and the Matanuska‐Susitna Borough. The 

population in the service area includes members of approximately 519 federally 

recognized tribes—all 229 federally recognized tribes in Alaska and approximately 

290 other federally recognized tribes from across the country. 

Families 

Served 

SCF’s Nutaqsiivik NFP Tribal Home Visiting Program serves pregnant, lowincome, AIAN mothers who are at high social and a medical risk and live in the 

defined service areas. 

Services 

Provided 

SCF uses NFP adapted to address the needs and concerns of AIAN women in 

the targeted service area who have more than one child, are at high social or 

a medical risk, and receive health care services through the Anchorage Native 

Primary Care Center or the Benteh Nuutah Valley Native Primary Care Center. 

Evaluation The evaluation contains two components: (1) using a historical comparisongroup design, comparing maternal and child health outcomes of participating 

families receiving the adapted NFP program to families who did not receive 

the adapted NFP program, and (2) using qualitative methods, exploring the 

cultural relevance and ability of the adapted NFP program to meet the needs 

of first-time mothers and mothers with multiple children. 
DESCRIPTION OF THE GRANTEES 43 

White Earth Nation 

The White Earth Nation (WEN) is a federally recognized tribe located on the 

White Earth Reservation in northwestern Minnesota. The reservation covers 

1,300 square miles encompassing three counties, five incorporated cities, and 

five major villages. There are 9,188 people living on the White Earth Reservation, 

4,029 identify themselves as American Indian. 

Families 

Served 

The White Earth home visiting program, Learning in the Family Environment 

(LIFE) Project and Parent Mentor Program, provides services to pregnant 

women, mothers, and caregivers who have children from birth to five years 

and who live on the White Earth Reservation. 

Services 

Provided 

The LIFE Project uses the NFP home visiting model for children from 

birth to age two and the White Earth Parent Mentor Program for children 

ages two to five. Cultural enhancements to the NFP model include using 

the Ojibwe language; books, stories, and materials that reflect activities 

that are culturally connected to the community; and storytelling and 

cultural and traditional values embedded in each lesson. The model was 

also modified to serve mothers with more than one child and adapted 

to include tailored requirements for nurse home visitor credentials, 

caseloads, and supervision. 

Evaluation Using a quasi-experimental interrupted time series design, the evaluation 

compares community resource access and service referral outcomes of 

mothers with multiple children who receive services through the NFP 

enhanced engagement strategy to outcomes for the same women prior to 

enrollment in the NFP program. 

Yerington Paiute Tribe 

The Yerington Paiute Tribe is a federally recognized tribe located in Lyon County, 

Nevada. Remote and rural in location, Lyon County comprises the Yerington 

Colony (22.34 acres adjacent to the City of Yerington) and the Yerington Paiute 

Reservation (also known as Campbell Ranch, which includes 1,633 acres located 

approximately 10 miles north of Yerington). 
 

44 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Families 

Served 

The Yerington Paiute Tribe’s Community Maternal Child Home Visiting 

Program serves AIAN pregnant women and parents and caregivers of children 

from birth to age five. 

Services 

Provided 

Services are provided using the PAT home visiting model, with enhancements 

to the curriculum including cultural education, smudging, Paiute language, 

cultural foods, and Paiute medicine. Group connections are enhanced using 

traditional activities such as crafts, storytelling, language, and information 

about other traditional events happening in the community. 

Evaluation The evaluation uses a single-case design to examine the relationship between 

participation in the enhanced PAT curriculum and changes in self-reported 

levels of stress and cultural engagement. 

COHORT 2 GRANTEES (FY 2011–2016) 

Confederated Salish and Kootenai Tribes 

The Confederated Salish and Kootenai Tribes (CSKT) is a federally recognized 

union of three tribes—Bitterroot Salish, Pend d’Oreille, and Kootenai—located on 

the 1.317 million acre Flathead Reservation in northwestern Montana. The local 

Salish Kootenai College serves as a nationally recognized tribal college, drawing 

students and families from over 70 different tribes to the reservation. 

Families 

Served 

The CSKT Tribal Home Visiting Program serves pregnant women, expectant 

fathers, and primary caregivers of children from birth to age five. 

Services 

Provided 

CSKT uses the PAT home visiting model with cultural enhancements that 

include involving elders at monthly group meetings and holding seasonal and 

special cultural activities that incorporate tribal language and traditions. CSKT 

is also implementing a leadership-training enhancement for PAT participants. 

Evaluation Using a quasi-experimental comparison-group design, the evaluation will 

examine retention and personal goal outcomes of adult participants who 

receive home visiting with a leadership component versus those that receive 

home visiting without leadership training opportunities. 

Eastern Band of Cherokee Indians 

The Eastern Band of Cherokee Indians (EBCI) is a federally recognized tribe whose 

rural reservation encompasses more than 56,000 acres of mountainous land in 

the five westernmost counties of North Carolina. As of December 2011, EBCI 

had over 14,500 members, and enrollment had increased 38 percent since 1995. 

More than half of EBCI members live on tribal lands. 
DESCRIPTION OF THE GRANTEES 45 

Families 

Served 

The EBCI Nurse Family Partnership Program serves AIAN mothers and 

pregnant AIAN women. 

Services 

Provided 

Services are provided using the NFP home visiting model, with a key 

adaptation to serve mothers with more than one child. This adaptation was 

rooted in a cultural concept of inclusiveness. The desire to care for all women 

and children is intrinsic to the Cherokee culture. 

Evaluation The evaluation uses a historical comparison group to examine the impact of 

NFP on maternal and child health outcomes. 

Native American Health Center, Inc. 

The Native American Health Center (NAHC) is an urban, nonprofit health 

organization that implements services in homes, clinical settings, institutions, and 

community centers across Alameda County in California’s San Francisco Bay Area. 

This area hosts one of the largest and most diverse urban AIAN populations in 

the United States, representing over 200 tribes and comprising 1.2 percent of the 

county population. 

Families 

Served 

NAHC’s Strong Families Tribal Home Visiting Project provides services to 

AIANs who are pregnant (teens and adults) or are parents or caregivers of 

AIAN children from birth to age three living in Alameda County. 

Services 

Provided 

NAHC uses the Family Spirit home visiting model, enhanced and augmented 

by the PIP curriculum. Adaptations to the Family Spirit model were made 

to suit the urban, intertribal community. Information from the Alameda 

County’s Comprehensive Perinatal Services Program Patient Information 

handouts on various perinatal health topics is also used to enhance the Family 

Spirit model. 

Evaluation Using a randomized case-control study design with a wait-list control group, 

the evaluation explores the impact of Family Spirit enhanced with PIP on 

parenting self-efficacy, responsivity, and the cultural connections of families. 

Riverside-San Bernardino County Indian Health, Inc. 

Riverside-San Bernardino County Indian Health is a federally recognized 

consortium of 10 sovereign Indian tribes located throughout California’s 

Riverside and San Bernardino counties. The rural and urban service area includes 

27,263 square miles encompassing 77 communities and is not restricted to 

the reservation areas. The consortium tribes are Agua Caliente, Cahuilla, Fort 

Mojave, Morongo, Pechanga, Ramona, San Manuel, Santa Rosa, Soboba, and 

Torres-Martinez. 
46 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Families 

Served 

The Riverside-San Bernardino County Indian Health Home Visiting Program 

serves pregnant women and families with children from birth to five years. 

Services 

Provided 

Services are provided using the PAT home visiting model. Enhancements 

to services include implementing a geographic information system (GIS) for 

locating services and other resources to respond to family needs.
	

Evaluation Using a stratified block randomization comparison-group design, the 

evaluation examines referral completion, parental empowerment, and child 

development outcomes among three groups: those receiving PAT enhanced 

with the GIS resource management system, those receiving PAT alone, and 

those receiving neither. 

Taos Pueblo 

Taos Pueblo is a federally recognized tribe located in north-central New Mexico. 

Approximately 1,500 enrolled tribal members live in and around the 100,000-acre 

rural reservation. Taos Pueblo has been home to the Taos Indians for over 1,000 

years and is the oldest continuously inhabited community in the United States. 

Families 

Served 

The Taos Pueblo’s Tiwa Babies Tribal Home Visiting Program serves families 

with children from birth to age five who reside on the Pueblo and within Taos 

County. Priority is given to families within the Tribal Home Visiting Program’s 

designated priority populations. 

Services 

Provided 

Using the Family Spirit home visiting model along with HIPPY, the Tiwa 

Babies Tribal Home Visiting Program believes that culture is the cornerstone 

for healthy families and children. Adaptations to the Family Spirit model 

include incorporating the Tiwa language and reinforcing traditions for 

nurturing infants; achieving balance with mind, body, and spirit; and sharing 

food, clothes, and essentials with others in need. 

Evaluation The evaluation focuses on the impact of incentives on family retention 

and dosage. Using a randomized comparison-group design, the evaluation 

compares implementation outcomes for families that receive two different 

incentive packages. 

United Indians of All Tribes Foundation 

The United Indians of All Tribes Foundation is an urban Indian organization that 

serves AIAN families in King County, Washington. King County comprises 2,134 

square miles and has a population of over 1.9 million people. It includes the 

Seattle metropolitan area and several other communities, a few of which are 

AIAN population bases. Residents of King County represent 41 tribal groupings 

and hundreds of individual tribes from across the United States and Mexico. 
 

 

DESCRIPTION OF THE GRANTEES 47 

Families 

Served 

The United Indians of All Tribes Foundation’s Ina Maka Family Program (IMFP) 

serves AIAN women who are pregnant or have infants or young children. 

Services 

Provided 

Services are provided using the PAT home visiting model. Cultural 

enhancements to the curriculum include hiring culturally competent staff 

members who have a strong understanding of AIAN culture, incorporating elders 

into the program, using traditional storytelling, conducting naming ceremonies, 

integrating traditional foods into nutrition discussions, and referring participants 

to cultural activities such as powwows and drumming or dancing classes. 

Evaluation Using a randomized comparison-group design, the evaluation compares the 

parenting outcomes of IMFP participants who receive the IMFP surface level 

cultural enhancements (simple additions to curriculum materials) and deep 

level cultural enhancements (addressing participants’ individual experiences 

around history, stressors, coping skills, and social supports) with those 

participants who receive only the surface level cultural enhancements. 

COHORT 3 GRANTEES (FY 2012–2017) 

Cherokee Nation 

The Cherokee Nation of Oklahoma is a federally recognized tribe located on a 

Tribal Jurisdiction Area consisting of 9,234 square miles within the 14 counties 

of northeastern Oklahoma. The Cherokee Nation of Oklahoma has over 300,000 

citizens, making it the country’s largest tribal nation. American Indians residing in 

the Cherokee Nation Oklahoma Tribal Jurisdiction Area account for roughly 

30 percent of Oklahoma’s American Indian population and nine percent of the 

total state population. 

Families 

Served 

The Cherokee Nation provides home visiting services to American Indian 

families and children from birth to five years. 

Services 

Provided 

The Cherokee Nation selected the SafeCare Augmented home visiting 

model and uses the PIP curriculum to incorporate cultural activities. 

Cultural enhancements to group meetings include topics such as traditional 

parenting, storytelling, lessons of the cradleboard, harmony in child rearing, 

traditional behavior management, and lessons of mother nature. In addition 

to implementing PIP at monthly group meetings, the program will invite 

Cherokee elders to the meetings to pass down their parenting wisdom. 

Evaluation Using a quasi-experimental design with a naturally occurring comparison 

group, the evaluation examines parent, child, and childhood neglect and 

abuse outcomes of families who receive the SafeCare Augmented program 

compared with those who do not. 
48 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Choctaw Nation of Oklahoma 

Receiving a second Tribal Home Visiting Program grant in Cohort 3, the Choctaw 

Nation serves five of the 10.5 counties through its Cohort 1 program (Project 

Chahta Inchukka) and the remaining counties through its Cohort 3 program 

(Project Chahta Vlla Apela). The target population and home visiting model are 

the same for both cohorts (see the description under Cohort 1 Grantees). 

Confederated Tribes of Siletz Indians 

The Confederated Tribes of Siletz Indians (CTSI) is a federally recognized 

confederation of 27 bands originating from northern California and southern 

Washington. Each of these tribes has a unique history, culture, and legal relationship 

with the federal government. CTSI’s service area includes 11 counties in Oregon. 

Families 

Served 

The Siletz Tribal Home Visiting Program provides home visiting services to tribal 

members residing in service area counties, with a focus on young children 

(prenatal through age three), children ages three to five who are not attending 

Head Start, expectant mothers and fathers, families facing hardships and stress, 

families coping with alcohol and substance use, elders who are caregivers, and 

families with a history of child neglect or maltreatment. 

Services 

Provided 

The Siletz Tribal Home Visiting Program uses the Family Spirit home visiting 

model. Adaptations to the model include incorporating the Athabaskan language 

in natural family settings and training home visiting staff in Safe Sleep techniques. 

Evaluation CTSI plans to examine parent stress, self-efficacy, and knowledge of child 

development through a single-case design evaluation that assesses families 

before, during, and after participation in the Your Growing Child curriculum 

module of Family Spirit. The grantee also plans to explore traditional community 

understandings of child development through a qualitative evaluation. 

Inter-Tribal Council of Michigan 

The Inter-Tribal Council of Michigan (ITCM) is a nonprofit organization that 

functions as a coalition of federally recognized tribes. It spans 19 counties 

in Michigan and includes five rural tribal reservation communities, one nonreservation community, and one urban program. The seven sites implementing 

the Tribal Home Visiting Program grant include: (1) the Bay Mills Indian 

Community, (2) Nottawaseppi Band of Huron Potawatomi, (3) Keweenaw Bay 

Indian Community, (4) Lac Vieux Desert Indian Tribe, (5) Little Traverse Bay Bands 

of Odawa Indians, (6) Match-E-Be-Nash-She-Wish Potowatomi Gun Tribe, and 

(7) the American Indian Health and Family Services of Southwestern Michigan. 
 

 

DESCRIPTION OF THE GRANTEES 49 

Families 

Served 

ITCM’s home visiting program, Partnership for Anishinaabe Binoojiiyensag 

Project, serves American Indian children who reside in the service area. 

Services 

Provided 

ITCM selected the Family Spirit home visiting model. Cultural adaptations to the 

model include: (1) adding an intense school readiness component by integrating 

evidence-informed early literacy tools and activities into visits with families of 

three to five-year olds; (2) adding content and demonstration activities to child 

development lessons for families with children ages two to five years (to support 

the development of early numeracy and letter recognition); (3) conducting 

Family Spirit prenatal lessons with mothers who want to begin the program 

before 28 weeks of gestation; (4) incorporating staff from a variety of professional 

backgrounds in home visits, including paraprofessionals, social workers, nurses, 

and early childhood development specialists; and (5) developing Ojibwe-, 

Odawa-, and Potawatomi-specific cultural adaptations and teachings. 

Evaluation Using a stepped wedge cluster randomization design, the evaluation examines 

child literacy and parenting outcomes of families who participate in services 

with early learning enhancements compared to families receiving standard 

Family Spirit home visiting services. 

Red Cliff Band of Lake Superior Chippewa 

The Red Cliff Band of Lake Superior Chippewa is a federally recognized tribe 

located on the rural Ojibwe reservation in northern Wisconsin. Sixty-four percent 

of members are children, youth, and young adults of childbearing age. Children 

from birth to age five are the fastest-growing segment of the population. 

Families 

Served 

The Zaagichigaazowin (ZHV) Home Visiting Program serves families who 

live on or within 15 miles of the Red Cliff Band of Lake Superior Ojibwe 

Reservation, with at least one primary caregiver who is a tribal member or is 

eligible for tribal membership. 

Services 

Provided 

Services are provided using the PAT home visiting model, with enhancements 

that include cultural teachings and activities, tribal programs and ceremonies, 

cradleboard-based teachings related to health and relationships. ZHV hires 

community-based doulas, individuals who specialize in supporting mothers during 

childbirth, to serve as PAT home visitors and child development specialists. 

Evaluation Red Cliff is using an interrupted time series design to examine whether 

participants in ZHV have better prenatal and perinatal health outcomes 

(prenatal alcohol use, smoking, breastfeeding, infant birth weight, vaginal or 

C-section birth, health events at birth, and prenatal care visits) than participants 

in a previous, less structured home visitation program. Red Cliff is also 

conducting a qualitative process evaluation to understand participant patterns 

of service use, quality of relationship with doula, and program fidelity. 
50 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Yellowhawk Tribal Health Center 

The Yellowhawk Tribal Health Center (YTHC) is a nonprofit, tribally governed, fully 

accredited ambulatory health clinic providing services to the Confederated Tribes 

of the Umatilla Indian Reservation in rural Umatilla County, Oregon. 

Families 

Served 

Services are provided to children from birth to age five, first-time mothers 

under 21 years, and pregnant women of any age who meet the Oregon 

Maternity Case Management high-risk eligibility criteria. Families with 

members who served in the Armed Forces have high priority for receiving 

services. 

Services 

Provided 

The YTHC Tribal Home Visiting Program uses the Family Spirit home visiting 

model, with enhancements such as encouraging program participants to 

share important cultural teachings, incorporating lessons about cradleboards, 

incorporating lessons from the PIP curriculum, and using a multigenerational 

approach to involve elders and other community members. 

Evaluation YTHC plans to evaluate parental stress outcomes for those who receive 

brief boosters to the Family Spirit curriculum through a single-case design 

approach. The YTHC team also plans to explore community breastfeeding 

supports through a qualitative evaluation. 
   7
 TECHNICAL ASSISTANCE
 PROVIDED 

Tribal Home Visiting Program grantees receive initial and ongoing technical 

assistance from several entities through cooperative agreements with ACF federal 

staff, the developers of the home visiting models, the Programmatic Technical 

Assistance for Tribal Home Visiting Center (PATH), and the Tribal Home Visiting 

Evaluation Institute (TEI). Extensive TA and capacity building support are provided 

to grantees on a variety of the following topics:10 

10 Direct quotations included throughout this report are excerpts from informal interviews conducted with Cohort 1 

grantees in spring 2015. Some quotations have been moderately edited for readability without altering their meaning. 

• Needs assessment and model selection 

•	 Program startup and implementation 

• Implementation fidelity monitoring 

• Recruitment and retention of home visiting staff and 

clients 

• Performance measurement and improvement 

• Data collection and data systems 

• Continuous quality improvement 

• Program evaluation 

“I think everything that 

ACF and our TA providers 

have offered has helped 

us to finish the work, and 

they know how to navigate 

through different phases. 

It’s been challenging, but 

we’ve had the appropriate 

resources available to us 

to be able to get to the 

level we need to be at.” 

– Cohort 1 Tribal Grantee 

Program Coordinator 

This coordinated support helped programs meet the grant 

requirements described in Chapter 5. Along with other 

program expertise and resources, this TA also provided 

a foundation for the growth in capacity and services 

described in the following chapter. 

51 
 

 

52 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

SUPPORT FROM ACF FEDERAL STAFF MEMBERS 

Tribal Home Visiting Program grantees engage in regular communication with 

ACF federal staff members regarding all grant-related activities. The cooperative 

agreements between grantees and ACF allow for extensive federal support on 

grant administration and management, implementation and service delivery, 

data collection, continuous quality improvement, and rigorous evaluation plans, 

among the many other facets of programming. Federal staff members from 

ACF support grantees in the form of monthly check-in calls, site visits, grantee 

meetings, and other as-needed communication. In addition, ACF staff members 

participate in conference calls, webinars, and meetings between grantees and the 

TA providers outlined in the rest of this chapter—model developers, providers of 

TA on program issues, and providers of TA on evaluation and data-related issues. 

TA FROM MODEL DEVELOPERS 

The developers of the program models provide training and support on program 

planning and implementation, adaptations to serve AIAN populations, data systems, 

methods for monitoring fidelity to the program model, and many other topics. 

Because each model developer’s support structure is different, grantees considered 

the amount and type of TA available when selecting a home visiting model. Table 

7-1 describes the TA available for each home visiting model used by tribal grantees. 

Table 7-1. Technical Assistance Provided by Home Visiting Model 

Model Technical Assistance Provided11 

Family Spirit The Family Spirit team at the Johns Hopkins University Center for American Indian Health 

works with organizations interested in implementing Family Spirit. This team assesses an 

organization’s readiness and capacity to implement the model and addresses any identified 

gaps. The Center provides staff training on the curriculum and program implementation 

for health educators, supervisors, and other program staff. In addition, frequent ongoing 

trainings for staff on topics such as maternal and child health, home visiting strategies, and 

case management are offered. It also conducts other TA activities during required quarterly 

meetings and on an as-needed basis. 

Organizations receive training, support, and TA with fidelity monitoring, evaluation 

Instruction 

Home 

and research, resource development, strategic alliances, and advocacy efforts. New 

for Parents programs receive two site visits that include home visitor training, orientation with 

agency administrators and collaborators, assistance with public relations events, and 

Youngsters 

of Preschool 

onsite coordinator training. Existing programs receive annual site visits to troubleshoot 

(HIPPY) programmatic issues, offer training to coordinators and home visitors, and assess program 

intervention fidelity. Trainers communicate with the sites leading up to each annual visit 

and provide a report with recommendations and action plans for quality improvement. 

HIPPY USA trainers contact their assigned programs monthly to discuss progress and provide 

assistance in solving implementation issues. 
TECHNICAL ASSISTANCE PROVIDED 53

Model Technical Assistance Provided11

Nurse Family 

Partnership 

(NFP)

The NFP National Service Office provides ongoing coaching and consultation to NFP nursing 

supervisors through nurse consultants. The Office has established a regional service team 

consisting of a program developer, nurse consultant, and regional quality coordinator, including 

staff dedicated to supporting tribal programs. Organizations can access technical support 

in the following nine areas: orientation to the program model and its implementation and 

evaluation requirements; community planning; selection of implementation agency or entity; 

staff recruitment, retention, consulting development, education, and coaching; program 

implementation; continuous quality improvement; research; evaluation; and contracts.

Parent-Child 

Assistance 

Program 

(P-CAP)

The University of Washington provides initial training on the P-CAP model, as well as annual 

trainings and Web-based refresher trainings as needed on site-specific topics. In addition, the 

P-CAP model developer is informed of program progress and TA needs through quarterly reports 

and phone calls. The program coordinator for the grantee using the P-CAP model has been 

invited to participate in Washington State’s P-CAP supervisors meeting to discuss challenges and 

successes in implementation. The model developer supports the implementation and adaptation 

of the model to tribal communities and recommends that the grantee share its experience 

implementing the model at professional conferences, at webinars, and through journal articles. 

Additional TA includes field observation and practice, as well as training on evaluation.

Parents as 

Teachers 

(PAT)

Guidance, training, and professional development opportunities are available to PAT affiliate 

programs through the national office’s Affiliations and Program Support department. PAT 

also has staff members dedicated to supporting tribal programs. PAT provides foundational 

and model implementation training; kindergarten entry training for programs serving 

children ages three to five; training on administering developmental, hearing, and vision 

screenings; and training for professionals working with special populations. 

SafeCare 

Augmented

The National SafeCare Training and Research Center (NSTRC) first works with interested 

programs to determine readiness to implement the model. Prior to training, NSTRC faculty 

and trainers prepare sites through conference calls and an in-person orientation visit to make 

sure the agency management and staff members to be trained understand the training and 

implementation process. NSTRC requires all SafeCare home visitors to complete a multiday 

workshop delivered by NSTRC trainers. Following the workshop, home visitors receive 

feedback on their implementation of SafeCare in the field from a SafeCare coach. NSTRC 

provides local programs TA in implementation and quality assurance for a minimum of one 

year after training. Home visitors implementing SafeCare Augmented also receive training 

in motivational interviewing from a member of the Motivational Interviewing Network of 

Trainers; ongoing training in motivational interviewing; and ongoing consultation from local 

experts in substance abuse, mental health, and intimate partner violence. 

11 The descriptions of TA provided by model developers were provided primarily by the HomVEE Web site (HHS, no date).

All program model developers worked with grantees during program planning and 

implementation. Model developers provided the training, monitoring, and support needed to 

implement the model with fidelity and provide high-quality services. The developers worked 

closely with grantees to design and implement acceptable adaptations to the models for AIAN 

populations while still maintaining the models’ core elements. They also provide varying 

degrees of support for data collection activities. 
 

54 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

TA FROM THE PROGRAMMATIC TECHNICAL 

ASSISTANCE FOR TRIBAL HOME VISITING CENTER 

PATH provides TA on program implementation to support grantee capacity 

building and support the provision of high quality, culturally relevant home 

visiting services. Zero to Three in partnership with Arizona State University’s 

Center for American Indian Projects, leads PATH.12

 PATH began in fall 2014. Walter R. McDonald and Associates, the Tribal Law and Policy Institute, and the FRIENDS 

National Resource Center previously provided programmatic technical assistance. 

 The ACF Office of the Deputy 

Assistant Secretary for Early Childhood Development administers the PATH 

contract. The following are PATH’s primary goals: 

•	 Respond to the needs of the Tribal Home Visiting Program 

•	 Support high-quality, evidence-based home visiting programs as part of a 

strong early childhood system that promotes the health and well-being of 

pregnant women, children from birth to kindergarten entry, and their families 

PATH offers TA along a continuum of intensity to meet the unique challenges and 

strengths of individual grantees. There are three levels of intensity. 

1.	 Universal technical assistance (raising awareness and sharing information): This 

level of TA provides recipients with up-to-date research and information pertaining 

to a variety of topics related to home visiting and early childhood development. 

Universal TA activities occur through the Web site, webinars, listservs, audio 

conference calls, grantee meetings, and the distribution of materials. 

2.	 Targeted technical assistance (building knowledge and skills): This level of 

TA provides recipients a deeper level of knowledge on a particular topic or on 

needs common to multiple grantees. One such activity may be teaching about 

EXAMPLES OF PROGRAMMATIC TECHNICAL ASSISTANCE 

Assessment and Planning: Community needs and readiness assessment, strategic planning, 

community engagement, organizational capacity and leadership 

Implementation: Adaptation and enhancement of home visiting models, implementation fidelity, 

culturally relevant practice, recruitment and retention of staff and families, referral and intake 

systems, continuous quality improvement, collaboration and partnership 

Sustainability: Dissemination, fiscal leveraging and sustainability, workforce and professional 

development, coordination of early childhood systems 

12
TECHNICAL ASSISTANCE PROVIDED 55 

implementing and sustaining a home visiting strategy and then encouraging 

participants to describe how the strategy could be employed in their tribal 

community. Targeted TA is delivered through in-person grantee meetings, 

webinars, and conference calls. 

3.	 Intensive technical assistance (increasing grantee capacity and improving 

implementation outcomes): With this level of TA, PATH works more intensely 

with individual grantees to move their work forward. TA providers customize 

this assistance to the context of the tribal community. PATH delivers this 

intensive TA through site visits to grantees as well as conference calls and 

Web meetings with grantee staff. PATH’s TA uses relationship-based and adult 

learning principles, such as creating an environment that supports openness 

to learning and working in partnership with participants to establish mutual 

interests and goals. 

TA FROM THE TRIBAL HOME VISITING 

EVALUATION INSTITUTE 

TEI provides TA to all grantees on evaluation and other data-related grant activities, 

such as performance tracking and measurement; design, implementation, and 

analysis for a rigorous evaluation; CQI; data systems; and ethical dissemination and 

translation of evaluation findings. James Bell Associates, Inc., leads the TEI team 

in partnership with the Centers for American Indian and Alaska Native Health and 

the Tribal Early Childhood Research Center at the University of Colorado School 

of Public Health, Johns Hopkins University Center for American Indian Health, 

Michigan Public Health Institute, and MDRC. The ACF Office of Planning, Research 

and Evaluation administers the TEI contract. 

Like PATH, TEI provides multiple levels of support to grantees. TEI delivers 

universal support through webinars, briefs, toolkits, grantee meetings, and 

facilitated peer learning opportunities and individualized TA through conference 

calls and Web meetings, site visits, and other in-person meetings. 

TEI strives to build local capacity to collect and use data to improve services for 

children and families, achieve better outcomes for families and communities, and 

better understand program impact. TEI builds capacity in three primary areas. 

1.	 Performance measurement: TA on benchmarks involves supporting grantees 

as they identify and operationalize performance measures; collect, analyze, 

and report data; and use data to understand program progress. 
 

56 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

EXAMPLES OF EVALUATION TECHNICAL ASSISTANCE
 

Performance Measurement: Developing benchmark measurement plans; operationalizing 

performance measures; developing data collection protocols; developing, selecting, and modifying 

data systems; analyzing data; reporting benchmark data 

Evaluation: Developing an evaluation question and design, understanding quasi-experimental 

designs, selecting culturally appropriate measures, developing an institutional review board 

application, evaluating cultural enhancements, disseminating evaluation findings 

Continuous Quality Improvement: Developing an organizational culture that values and uses data, 

conducting Plan-Do-Study-Act cycles, using data to understand existing processes and drive program 

improvements, facilitating CQI peer learning communities 

2.	 Evaluation: TA on evaluation involves assisting grantees in the development of 

an evaluation question and design that are both important and acceptable to 

the local community and of interest to the broader tribal home visiting field. 

3.	 Continuous quality improvement: TEI provides assistance on CQI through 

hands-on, in-person training to grantee teams on using the Plan-Do-StudyAct cycle. This cycle is an iterative, four-stage problem-solving method for 

improving a process or carrying out change (Tews et al., 2008). CQI involves 

using data to systematically identify areas for improvement and to test and 

measure the effect of planned improvements. 

TEI uses a capacity building approach that emphasizes relationship and skill building. 

TEI draws on the Roadmap for Collaborative and Effective Evaluation in Tribal 

Communities (Tribal Evaluation Workgroup, 2013) and incorporates the following 

core elements of effective support: 

•	 Respect for tribal processes and decision making by recognizing tribal 

sovereignty and autonomy 

•	 Approaches that support and incorporate substantial community input into 

evaluation and performance measurement 

•	 Iterative, step-by-step processes informed by research on adult learning 

•	 Consistent, long-term involvement with grantees 

•	 Frequent and responsive contact through a variety of modalities 

•	 Emphasis on and promotion of bidirectional learning 

•	 Acknowledgment of indigenous ways of knowing and western science as 

equally relevant forms of knowledge 
   

8 

TRIBAL HOME VISITING 

SERVICES: BUILDING 

PROGRAMS TO REACH
 HIGH-NEED FAMILIES 

Required program activities and support from federal staff and TA providers 

helped grantees successfully reach and serve vulnerable families and children 

in at-risk communities. Demographic and service data from FY 2012 through 

FY 2014 demonstrate significant increases in program capacities and increased 

service delivery to some of the highest-need families. The findings below 

describe these increases in program capacities and service delivery and the 

characteristics and demographics of the families served. Unless otherwise noted, 

findings represent data submitted by all 25 grantees for participants enrolled in 

FY 2014. Information from informal interviews conducted with the first cohort of 

grantees (13 grantees) is also integrated throughout the chapter. 

INCREASED PROGRAM REACH AND CAPACITY 

During FY 2012 through FY 2014, enrollment and home visits increased. Program 

capacities also improved but were not as easily captured in data. For example, 

grantees raised awareness and support for their programs and carefully built 

processes and infrastructure to deliver high-quality, community-based services. 

The Tribal Home Visiting Program increased the reach of services in tribal 

communities. In 2014, 870 families were enrolled, over five times the number 

of families enrolled in 2012 (Figure 8-1). Grantees also increased the number 

of home visits provided annually, conducting 17 times more home visits in 2014 

than 2012 (Figure 8-2). Within a short time period and with limited grantee 

experience in home visiting, a total of 1,523 unique families, which included 

1,700 adult participants and 1,497 children, were enrolled. These families 

received nearly 20,000 home visits from 2012 to 2014. 

57 
 

  

58 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Figure 8-1. Growth in Participants Figure 8-2. Growth in Home Visits 

Grantees worked to build community awareness and acceptance of 

home visiting. Many grantees needed to address the negative history and 

assumptions related to home visiting in their communities. In some tribal 

communities, people associate home visits with child protection investigations. 

There were also struggles with the lack of community awareness of the need 

for early childhood development and education. The grantees confronted 

these challenges by providing consistent, quality services and engaging in 

outreach activities to inform the community of the program and address any 

concerns. 

“If you had a nurse come into your home in years 

past, it was because your child was being taken 

away.

”- Cohort 1 Tribal Grantee Data Manager 

Building capacity and providing quality services that met community needs. 

The growth in services reflects, in part, the thoughtful preparation that each 

grantee undertook prior to implementation. For many grantees, the provision 

of evidence-based services and collection of program data required a new level 

of program capacity. To provide quality services, grantees engaged in extensive 

planning, including developing policies and procedures, creating data collection 

protocols, and conducting thorough training of staff. Program models were 

carefully adapted to ensure that services fit each unique community context and 

culture. 

“For the very first time the staff began to see that 

what they do in the homes, what they document on the 

forms, and the tools that they use were really important 

because it eventually added up to that bigger, broader 

picture.”- Cohort 1 Tribal Grantee Project Director 
 

 

TRIBAL HOME VISITING SERVICES: BUILDING PROGRAMS TO REACH HIGH-NEED FAMILIES 59 

PRIORITIZING THE HIGHEST-NEED FAMILIES 

Grantees used home visiting services to reach families struggling with 

multiple challenges, including poverty, unemployment, limited education, 

and histories of substance abuse (See Lesson From the Field below) and child 

maltreatment. The needs of families served frequently matched those of 

“priority populations” outlined in the legislation. To address the critical needs 

of these families, approaches in the delivery of services needed to be creative 

and flexible. 

LESSONS FROM THE FIELD 

Tribal Home Visiting grantees are working hard to make a difference for families 

struggling with substance abuse. 

We are impressed with “clients involved in a substanceusing lifestyle who are willing when they find out they are 

pregnant to go to treatment. With our support they stay in 

recovery so that their babies have a chance at being born 

healthier. I think this has been huge in our community.” 

- Cohort 1 Tribal Grantee Home Visitor 

Grantees serving families struggling with substance use may face extra challenges in 

meeting program requirements. Instead of screening out these families, however, 

grantees prioritize them and work creatively to keep them engaged. Grantees 

are committed to serving families struggling with substance abuse even if their 

engagement is sporadic. 
60 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Families were often living in poverty. Seventy-one percent of participants had a 

family income at or below federal poverty guidelines (at or below $11,670 for an 

individual or $23,850 for a family of four in 2014). Almost half (43 percent) of the 

families were at or below 50 percent of the federal poverty guidelines (Figure 8-3). 

Figure 8-3. Family Income Relative to Federal 

Poverty Guidelines, 201413 

13 N = 956. 

Children in the critical ages of birth to five years served. Seventy-eight percent 

of child participants were under three years of age, and almost half (45 percent) 

were between one and two years (Figure 8-4). Eighty-five percent of children 

were American Indian or Alaska Native.14 

14 Of the children that were not identified as AIAN, 11 percent identified as more than one race, four percent 

as White, and one percent as “other.” Individual grantees had the authority to determine service eligibility, 

and some programs chose to serve families in their service area regardless of whether they were AIAN.
 

Figure 8-4. Child Participant Age, 2014 
TRIBAL HOME VISITING SERVICES: BUILDING PROGRAMS TO REACH HIGH-NEED FAMILIES 61

Caregivers were often young, single parents and pregnant women. In FY 2014, 

a majority (84 percent) of adult program participants were between the ages 

of 18 and 34 years (Figure 8-5). Thirty-one percent of adult participants were 

pregnant at enrollment, 59 percent were female caregivers, and 10 percent were 

male caregivers (Figure 8-6). Adult participants were mostly single (70 percent), 

and a quarter was married (Figure 8-7). Seventy-eight percent of adults served 

were American Indian or Alaska Native. 

Figure 8-5. Adult Participant Age, 201415

15 N = 1,344. Excluded unknown.

 

Figure 8-6. Type of Adult Participant, 201416

16 N = 1,441. Excluded unknown.

  

Figure 8-7. Participant Marital Status, 201417

17 N = 1,205. Excluded unknown.
 

      

62 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

A majority of caregivers were not employed and did not have a college education. 

Most adult participants were not employed (59 percent), and most were not 

students or trainees (85 percent) (Figures 8-8 and 8-9). The highest educational 

attainment for most adult participants was high school (36 percent) or less than 

high school (21 percent). Only 16 percent of adult participants had some college or 

training (without earning a degree), while eight percent had an associate’s degree 

and four percent had a bachelor’s degree or higher (Figure 8-10). 

Figure 8-8. Participant Employment, 201418 

 N = 1,187. Excluded unknown. 

 

 

 

Figure 8-9. Participant Student Status, 201419 

 N = 1,093. Excluded unknown. 

 

Figure 8-10. Participant Educational Attainment, 201420 

 N = 1,132. Excluded unknown. 

18

19

20
 

TRIBAL HOME VISITING SERVICES: BUILDING PROGRAMS TO REACH HIGH-NEED FAMILIES 63 

Participants experienced multiple challenges. Most 

families that received home visiting services had 

multiple challenges. These challenges, whether they 

were past or current issues, were frequently priority 

areas defined by the Home Visiting Program legislation 

(Figure 8-11). Many families struggled with poverty, 

substance use, a history of child maltreatment, and 

children’s academic and cognitive challenges. Sixtynine percent of individuals newly enrolled during 

2014 were considered low income as defined by an 

income at or below 100 percent of the federal poverty 

guidelines.21

 Figure 8-3 and Figure 8-11 differ slightly in their percentages related to poverty. Figure 8-3 (Family Income Relative 

to Federal Poverty Guidelines, 2014) reflects all families served in the year, and Figure 8-11 (Percentage of Newly 

Enrolled Families in Priority Populations, 2014) reflects families newly enrolled in 2014. 

 Over one-quarter of families newly 

enrolled in 2014 (28 percent) had a history of substance 

abuse or were in need of substance abuse treatment. 

“Families come here for 

substance abuse treatment 

from the surrounding 

villages. When that 

treatment is completed, 

families go back to the 

village and they have to 

exit the program because 

home visitors are not able 

to go to the village and visit 

them.” – Cohort 1 Tribal 

Grantee Program Director 

Thirteen percent of newly enrolled participants had a history of child abuse 

or neglect. Families with these struggles were prioritized, but often the same 

challenges that brought families to home visiting also made it difficult for them 

to complete the program. 

Figure 8-11. Percentage of Newly Enrolled Families in Priority Populations, 

2014 (N = 932) 

21
64 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

The success of grantee programs expanding services and serving high-need 

families was made possible through creative and flexible programing. In addition 

to having multiple risk factors, many families lived in home environments that 

complicated the delivery of home visiting. When the home was not the ideal 

place for a family to receive services, visits at the program office or in other 

neutral locations were provided. One program provided services in the office 

for homeless families or families whose housing situation was not amenable to 

services. In another program, a home visitor broke down barriers between the 

jail and tribal health programs to gain professional visitor status and work with 

incarcerated fathers of enrolled children. Grantees also demonstrated flexibility 

in serving additional family and/or household members that were present 

during home visits (See Lesson From the Field below). Throughout, grantees 

demonstrated a commitment to delivering services regardless of the challenges 

faced by each individual family. As will be clear in the following chapter, this 

commitment to families had important results for both program delivery and 

family outcomes. 

LESSONS FROM THE FIELD 

Home visiting often benefits multiple children and family members beyond those directly 

served by the program. 

“I currently work with a family that has four children under 

the age of five. Of course we talk about all of them and do 

activities with all of them. You can’t sit down on the floor 

with some kind of exciting book or activity and tell two 

of them to go away.” – Cohort 1 Tribal Grantee Program 

Coordinator
 

Many home visiting programs work with families with multiple children and sometimes 

extended family members or friends living in the home. Home visitors report only on one 

index child, which cannot reflect the impact of home visiting on the family as a whole. 
   9 FULFILLING THE PROMISE 

OF THE TRIBAL HOME 

VISITING PROGRAM 

In addition to expanding the reach of high-quality and culturally relevant 

home visiting in tribal communities, the Tribal Home Visiting Program aimed 

to improve the quality of home visiting programs to better serve vulnerable 

families in at-risk communities. To monitor program progress towards 

meeting this goal, grantees defined and monitored program performance 

measures in six benchmark areas. This section summarizes the Cohort 1 

grantees’ development of performance measurement plans and their program 

performance from FY 2012 to FY 2014. 

MONITORING PROGRAM PERFORMANCE IN 

BENCHMARK AREAS 

As required, tribal grantees adhered to the same high standards and 

expectations of the State Home Visiting Program with respect to monitoring 

program performance. Grantees developed performance measurement 

plans detailing their approach for collecting, analyzing, and reporting 

performance data in six legislatively mandated benchmark areas (Table 

9-1). Each benchmark area includes multiple constructs. Constructs capture 

distinct topics relevant to each benchmark area. For example, one construct 

within the benchmark area of “Maternal and Newborn Health” is “Prenatal 

Care.” 

65 
66 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Table 9-1. Benchmark Areas and Number of Constructs
 

Benchmark Area 

Number of 

Constructs 

Maternal and Newborn Health 9 

Child Injuries, Child Abuse, Neglect, or Maltreatment and Emergency 

Department Visits 

7 

School Readiness and Achievement 9 

Crime or Domestic Violence 5 

Family Economic Self-Sufficiency 3 

Coordination and Referrals for Other Community Resources and Supports 5 

GRANTEE PERFORMANCE MEASUREMENT PLANS 

Developing Performance Measurement Plans

and Grantee Capacities 

Tribal grantees, like state grantees, selected and developed their own 

performance measures for each construct to ensure they were meaningful 

for their programs. As such, performance measures are not uniform across 

grantees. For example, to measure child injuries, some grantees measured 

the percentage of children with injuries requiring medical treatment. Other 

grantees measured the number of incidents of child injuries requiring medical 

treatment. In this example, the unit of measurement for some grantees is 

children, while the unit of measurement for others is incidents. 

In developing performance measurement 

plans, grantees considered community 

and cultural contexts; service settings; 

availability of services in the community; 

and feedback from local community, 

tribal, and organizational leaders. 

Grantees engaged in an iterative, or stepby-step, process to develop performance 

measurement plans. This process 

included multiple feedback cycles with 

community members and technical 

“This was an opportunity to 

change how data was collected 

and managed and to build 

infrastructure. I saw it as 

something very advantageous 

for the tribe over the long term 

because that infrastructure is 

still going to be there moving 

forward.” – Cohort 1 Tribal 

Grantee Evaluator 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 67 

assistance providers. For grantees, this process raised concerns about a lack of 

screening and assessment measures formally validated with AIAN children or 

families. Grantees grappled with these and other issues as they developed plans 

that would provide their program with needed information and fulfill legislated 

requirements for demonstrating program improvement. Developing performance 

measurement plans and necessary systems of support was a new endeavor for 

many grantees and communities and resulted in enhanced program and community 

capacities. Program and community capacity building benefits the Tribal Home 

Visiting Program, the broader community, and future community efforts (See 

Lesson From the Field below). For example, the program provided community 

members with significant opportunities for personal and professional growth. 

LESSONS FROM THE FIELD 

Home visiting programs are building capacity throughout the community by providing 

an opportunity for professional and personal growth. 

“Another thing is the growth of the staff. I’m really proud of 

that because I’ve seen them grow, not only as workers but 

as individuals, as parents, and even as a child, as a mother, 

as a wife, everything, and that’s made me really happy.” 

– Cohort 1 Tribal Grantee Project Coordinator 

One important but perhaps not always intentional result of the home visiting programs 

is the impact on the home visitors themselves. Most home visitors are from the 

community in which they serve. Becoming a home visitor allows these individuals to 

learn new professional skills, such as data collection, as well as apply their personal 

experiences to support families in their communities. This professional development 

sometimes extends to the enrollees. In at least one program, a mother who had 

recently graduated felt confident enough in what she had learned as a participant in 

the program to apply for a position as a home visitor. Even though this outcome and 

those like it are not tracked, the staff members are proud that an enrollee was inspired 

to translate her own personal and professional growth achieved through the program 

into helping other families in her community. 
 

68 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Data on program performance measures were reported using the Discretionary 

Grant Information System—Tribal Home Visiting, the first national data system for 

home visiting in tribal communities. This HRSA-administered online data system 

collects performance measure data to help government project officers monitor 

and support grantees. 

Cohort 1 Grantee Program Performance 

The following section summarizes program performance for Cohort 1 grantees 

(n = 13), organizations awarded grants in 2010 in benchmark areas from FY 2012 

to 2014.22 

 Grantees began collecting benchmark data when they started providing services to families. Implementation start 

dates ranged from April 2012 to May 2013. 

Three primary data sources were used to summarize grantee program 

performance. Details for each of the data sources are provided below. The three 

primary data sources include the following: 

1. ACF determinations of program 

improvement based on FY 

2012 baseline and FY 2014 

comparison data for each 

construct 

2. Aggregation of FY 2012 through 

FY 2014 data for constructs with 

similar performance measures 

across at least five grantees 

3. Informal interviews with Cohort 

1 grantees on their experiences 

with program performance 

measures and data reporting 

A NOTE ON DATA LIMITATIONS 

Variability in grantee-defined performance 

measures limits discussions of program 

performance to the proportion of 

grantees that improved performance. 

Specific interpretations of program 

performance are relative to how an 

individual grantee defined its performance 

measures. For more information on 

limitations see Appendix C. 

ACF Determinations of Program Improvement 

Benchmark data, reported to ACF from the beginning of program 

implementation through December 2014, were used to determine grantee 

improvement. For each construct, grantees reported baseline data collected 

from when services began through FY 2013 and comparison data collected in 

FY 2014. ACF determined improvement for each construct using the following 

decision rules: 

22
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 69 

• To demonstrate improvement in a given construct, comparison values had to 

move in a positive direction or maintain a high level of performance. 

• To demonstrate improvement in an individual benchmark area, improvements 

in at least half of the constructs within the benchmark area were required. 

• To demonstrate overall program improvement, improvements in at least four 

of the six benchmark areas were required. 

Due to variability in individually defined performance measures across grantees, 

the summary of grantee program performance is limited to reporting the number 

and percentage of grantees that demonstrated improvement in performance 

measures for constructs, improvement in benchmark areas, and overall 

improvement. Outside of indicating the number and percentage of grantees that 

demonstrated improvement, the specific interpretation of what improvement 

means is relative to how individual grantees defined their performance measures. 

Data Aggregation for Select Constructs 

To provide additional information on grantee program performance, data 

for constructs with similar performance measures were aggregated across 

grantees. Specifically, grantee-level data from FY 2012 through FY 2014 were 

combined across grantees to provide a snapshot of program performance on 

select constructs.23

23 Appendix B provides more information on the decisions and processes for aggregating benchmark data. 

 This process included a careful review of grantee-defined 

performance measures across all constructs to identify constructs with similar 

performance measures. Data were aggregated for a construct if sufficient 

alignment in performance measures existed across at least five grantees and 

it allowed for meaningful data aggregation and interpretation. It is important 

to note that the percentage and rates provided in the data aggregation do not 

represent all enrolled program participants included in the analysis. Grantees 

typically defined a smaller pool of eligible participants for particular measures. 

For example, many grantees only included women who had given birth in the 

last six months as eligible for maternal depression screening. Therefore, the 

percentage provided represents the percentage of women who had given birth 

in the past six months who were screened for maternal depression and not the 

percentage of all enrolled women who were screened for maternal depression. 

Table 9-2 presents a list of the constructs and measures selected for data 

aggregation. Results from data aggregation appear throughout the findings on 

program improvement. 
70 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Table 9-2. Constructs and Measures Identified for Data Aggregation
	

Construct Performance Measure 

Prenatal Care Percentage of eligible participants initiating early 

prenatal care 

Screening for Maternal Depressive Symptoms Percentage of eligible participants screened for 

maternal depression 

Regular Visits to a Primary Healthcare Provider or 

Medical Home 

Percentage of eligible participants with visit to a 

primary healthcare provider or medical home 

Information Provided or Training on Prevention of 

Child Injuries 

Percentage of eligible participants who received 

information or training on prevention of child injuries 

Incidence of Child Injuries Requiring Medical Treatment Rate of child injuries requiring medical treatment 

First-Time Victims of Maltreatment for Children in 

Program 

Rate of first-time victims of maltreatment 

Child Screening Rates in Developmental Domains Percentage of eligible children screened in 

developmental domains 

Screening for Domestic Violence Percentage of eligible participants screened for 

domestic violence 

Household Income Percentage of eligible participants with increased 

household incomes or benefits 

Number of Families Identified for Necessary Services Percentage of eligible families screened for necessary 

services 

Number of Families that Required Services and 

Received a Referral to Available Community Resources 

Percentage of families identified for necessary services 

that received a referral 

Number of Completed Referrals Percentage of families receiving a referral that 

completed the referral 

Informal Interviews with Grantees 

To contextualize grantee program performance and further understand grantee 

perspectives, this chapter summarizes findings from informal qualitative 

interviews with Cohort 1 grantees. During informal interviews, representatives 

for each grantee responded to a unique set of questions addressing issues most 

relevant to the measurement and programmatic issues of that grantee. Custom 

interview guides were developed for each interview. Interviews were audio 

recorded, transcribed, and coded for emerging themes. Grantee perspectives, 

experiences, and direct quotations provided throughout the report draw from 

interview data. Some quotations have been moderately edited for readability, 

but the original meaning and intent were maintained. 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 71

OVERALL IMPROVEMENT 

The legislation and subsequent guidance establish expectations for grantee 

improvement in benchmark areas. Specifically, improvement within an 

individual benchmark area is defined as demonstrating improvement in at 

least half of performance measures for constructs within the benchmark 

area. Overall improvement is defined as improving in at least four of the six 

benchmark areas.24

24 Appendix A describes how program improvement was defined.

A majority (77 percent, n = 10) of the 13 Cohort 1 grantees demonstrated overall 

improvement in the benchmark areas in the three-year period. Within each 

benchmark area, the percentage of grantees demonstrating improvement ranged 

from 62 percent to 85 percent (Figure 9-1). 

Figure 9-1. Percentage and Number of Grantees Improved Overall 

and in Individual Benchmark Areas (N = 13)

INDIVIDUAL BENCHMARK AREA IMPROVEMENTS

A Healthy Foundation: Maternal and Newborn Health

The maternal and newborn health benchmark area includes constructs related to the 

health and well-being of mothers and children. Examples include access to a primary 

health care provider, adequate and timely prenatal care, maternal mental health 

screening, and initiation of breastfeeding. Program improvement across these 

constructs supports a wide range of positive maternal and child health outcomes. 
72 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Grantee Improvements in Maternal and Newborn Health 

Increased participant use of a primary health care provider. Greater use of a 

primary health care provider or medical home translates to higher quality health 

care services and more equitable health outcomes across populations (Starfield 

et al., 2005). 

Almost all grantees (92 percent, n = 12) improved performance measures for 

participant visits to a primary health care provider or medical home. During FY 

2012 through FY 2014, 40 percent of eligible participants from 10 grantees with 

similar performance measures visited a primary health care provider or medical 

home. In some cases, parents were encouraged to access specialized medical 

screenings and services (See Lesson From the Field below). 

LESSONS FROM THE FIELD 

Home visiting supports maternal and child health. 

Any parent knows it’s hard to take care of a child when you are struggling with your own 

unmet needs. Because home visitors form such close relationships with the families 

they serve, they can be the first people to identify parents’ unmet needs. In addition 

to identifying issues through screening protocols, home visitors can also discover other 

health-related issues and support families in accessing care. One home visitor was able 

to help a young mother get diagnosed with a fetal alcohol spectrum disorder (FASD), 

which opened up access to various benefits. As a result, she was able to get the support 

she needed to keep custody of her children. 

“She is a great mom, a great mom—those kids get to be 

raised by their mom and stay in their home and not be 

subjected to our foster care system. That is a huge success.” 

– Cohort 1 Tribal Grantee Project Director
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 73 

Promotion of key determinates of positive birth outcomes, such as early 

initiation of adequate prenatal care. Timely and adequate prenatal health care 

promotes positive birthing outcomes and reduces infants’ risks for complications 

(CDC, 2006; Eckstrand et al., 2012). 

A majority of grantees (77 percent, n = 10) improved performance measures of 

prenatal care. During FY 2012 through FY 2014, 89 percent of eligible participants 

from seven grantees with similar performance measures initiated prenatal care by 

the first or second trimester. 

Increased screening rates for maternal depressive symptoms. Early 

identification of and referrals for maternal depression mitigates the negative 

child outcomes associated with maternal depression. Early identification and 

treatment is especially important for low-income populations, who are less likely 

to receive treatment for depression (Claessens et al., 2015; Olfson et al., 2002). 

“For the depression screening, it’s really good, it’s really easy. 

The home visitors are comfortable administering it, and lots 

of times there are things that come out of it that we wouldn’t 

know if it wasn’t administered.” – Cohort 1 Tribal Grantee 

Project Coordinator
 

Most grantees (77 percent, n = 10) improved screening rates for maternal 

depression. During FY 2012 through FY 2014, 12 grantees with similar 

performance measures screened 71 percent of eligible participants for maternal 

depression. Maternal depression screenings were used to identify family needs 

and initiate important conversations about sensitive topics. Through this process, 

home visitors served as valuable sources of support and guidance for families. 

Grantees also provided staff training on administering maternal depression 

screenings and working with families when maternal depression is present to 

optimize the benefits of screening. 

Increased initiation and duration of breastfeeding. Early initiation of 

breastfeeding is linked to positive child health outcomes, better long-term 

cognitive development, greater adult education, and higher adult incomes 

(Ip et al., 2007; Victora et al., 2015). 

Most grantees (62 percent, n = 8) improved performance measures for 

initiation and duration of breastfeeding. Grantees engaged in significant 

program and community efforts to address social norms around breastfeeding. 

Several grantees noted that breastfeeding was not a common practice in 

their communities. Work with community partners (such as the local Special 
74 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Supplemental Nutrition Program for Women, Infants, and Children program 

[WIC] or the local library) and lactation counselors emphasized the importance 

of breastfeeding and provided mothers with private areas to breastfeed. One 

grantee also held a conference specifically focused on breastfeeding, hiring a 

Native American lactation consultant to speak with pregnant women and new 

mothers about the benefits of the practice. 

“The culture with grandmothers and great grandmothers, 

was not to encourage breastfeeding for a lot of historical 

reasons. We have been able to reach our young moms and 

see a change in breastfeeding.” – Cohort 1 Tribal Grantee 

Project Coordinator 

Table 9-3. At a Glance: Grantee Improvement in Maternal and 

Newborn Health (N = 13) 

Construct 

Sample Performance Measures 

Grantees Improved 

% (n) 

Regular Visits to a Primary Healthcare Provider or Medical Home 

Children and mothers who visit primary health care provider or medical home 

92 (12) 

Prenatal Care 

Receipt of timely and adequate prenatal care 

77 (10) 

Screening for Maternal Depressive Symptoms 

Screening among pregnant mothers, postpartum mothers, or all enrolled mothers 

77 (10) 

Parental Use of Alcohol, Tobacco, and Illicit Drugs 

Tobacco, alcohol, or illicit drug use among pregnant mothers or all enrolled mothers 

or screening and referral for substance use 

69 (9) 

Preconception Care 

Program provision of preconception care information, postpartum checkups, 

preventative exams, or vitamin use among postpartum mothers or all enrolled mothers 

69 (9) 

Breastfeeding 

Initiation of breastfeeding or duration of breastfeeding 

62 (8) 

Maternal and Child Health Insurance Status 

Children and mothers with health insurance 

46 (6) 

Inter-Birth Intervals 

Program provision of information on birth spacing, participant contraception use, or 

six to 12-month pregnancy spacing 

38 (5) 

Well-Child Visits 

Receipt of timely and adequate well-child visits or current on recommended 

immunizations 

31 (4) 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 75 

Prevention of Adverse Experiences: Child Injuries; Abuse, Neglect,

or Maltreatment; and Emergency Department Visits 

This benchmark area includes constructs related to the prevention of adverse 

early childhood experiences. Constructs include training and information on 

prevention of child injuries; reductions in child injuries; and reductions in child 

abuse, neglect, or maltreatment and emergency department visits. Focused 

attention on these constructs prevents adverse early childhood experiences, 

which predict a wide variety of negative outcomes, including poor adult health 

and well-being (Felitti et al., 1998). 

Grantee Improvements in Child Injuries, Abuse, Neglect, or

Maltreatment and Emergency Department Visits 

Reduced rates of substantiated reports and first-time victims of child 

maltreatment. Children exposed to adverse early experiences, including 

maltreatment, demonstrate a range of negative outcomes (Felitti et al., 1998; 

Duncan et al., 2010; Shonkoff & Garner, 2012). AIAN children are often 

overrepresented among child 

maltreatment victims, at more than 

1.6 times national levels (HHS, 2007). 

Almost all grantees (92 percent, n = 

12) reduced rates for substantiated 

reports and first-time victims of 

child maltreatment. During FY 2012 

“There’s been training, and home 

visitors are sent to conferences, so 

there’s a heightened awareness 

of maltreatment and what to do 

and how to talk with families.”

 – 

Cohort 1 Tribal Grantee Evaluator 

through FY 2014, the average rate of 

first-time victims of child maltreatment across grantees was 10 percent. Training 

and professional development were provided to home visitors on recognizing 

and addressing early warning signs of child maltreatment. Despite program 

improvements in reducing first-time child maltreatment rates, the average rate 

of 10 percent for first-time victims of child maltreatment needs to be considered 

in the context of the proportions of high-risk families some grantees serve. For 

some grantees, families are referred to home visiting programs due to existing 

reports of suspected or substantiated child abuse or maltreatment. 

Provision of information or training on the prevention of child injuries and 

decreased child injuries requiring medical treatment. Unintentional injuries 

are a leading cause of death and disability among children and adolescents 

ages 0 to 19 (CDC, 2012). Fortunately, many child injuries can be prevented by 

providing parents with knowledge and/or training to improve the safety of home 

environments for children birth to five years. 
76 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Rates (69 percent, n = 9) of information sharing or training on preventing child 

injuries increased. During FY 2012 through FY 2014, 50 percent of eligible families 

from 12 grantees with similar performance measures received information or 

training on preventing child injuries. A majority (77 percent, n = 10) also reduced 

rates of child injuries. During FY 2012 through FY 2014, the average rate of 

child injuries requiring medical treatment among eight grantees with similar 

performance measures was three percent. 

Continued progress toward reduced mother and child emergency department 

visits. More than half the grantees improved on measures of mother and 

child emergency department visits (39 percent and 54 percent of grantees, 

respectively), a finding that reflects specific community contexts. In remote 

villages, families do not typically visit primary care doctors or emergency 

departments due to limited transportation options. Additionally, some service 

populations regularly use emergency departments to access routine medical 

care. Because families are increasingly accessing primary care and other routine 

medical care, as demonstrated in the benchmark area of maternal and newborn 

health, improvement in emergency department visits may result. 

Table 9-4. At a Glance: Grantee Improvement in Child Injuries; Abuse, Neglect, 

or Maltreatment; and Emergency Department Visits (N = 13) 

Construct 

Sample Performance Measures 

Grantees Improved 

% (n) 

Reported Substantiated Maltreatment for Children in Program 

Number of children or families with substantiated reports of maltreatment or number 

of substantiated reports of maltreatment 

92 (12) 

First-Time Victims of Maltreatment for Children in Program 

Number of children who are first-time victims of maltreatment 

92 (12) 

Incidence of Child Injuries Requiring Medical Treatment 

Number of children with injuries or number of incidents of injuries 

77 (10) 

Information Provided or Training on Prevention of Child Injuries 

Provision of information or training on prevention of child injuries 

69 (9) 

Reported Suspected Maltreatment for Children in Program 

Number of children or families with reports of suspected maltreatment or number of 

reports of suspected maltreatment 

69 (9) 

Visits for Children to Emergency Department From All Causes 

Number of children with visits to the emergency department or number of child visits 

to the emergency department 

54 (7) 

Visits for Mothers to Emergency Department From All Causes 

Number of mothers with visits to the emergency department or number of mother 

visits to the emergency department 

38 (5) 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 77 

A Path to Success: School Readiness and Achievement 

This benchmark area measures key predictors of school readiness and 

achievement. Constructs include supportive parenting behaviors, healthy 

parent–child relationships, and regular screenings to monitor child 

development across multiple domains. These constructs promote school 

readiness and achievement, ensuring a strong start on a child’s path to 

academic success. 

Grantee Improvements in School Readiness

and Achievement 

Improved parent well-being and reduced parenting 

stress. Parent emotional well-being and low parenting 

stress support healthy parent–child interactions that in 

turn predict school readiness and academic achievement 

(Adi-Japha & Klein, 2009; Thompson, 2008; Adirim & 

Supplee, 2013). 

Almost all grantees (92 percent, n = 12) improved 

performance measures for parent well-being and stress. 

Programs often served as a vital source of social support 

for families, helping to relieve daily stresses and improve 

parent well-being (See Lesson From the Field below). 

“I worked with a young lady 

who just had no one. She 

told me, ‘You know, you 

were the mother that wasn’t 

able to be there with me. I 

didn’t have a mother and 

you were the mother when

I was pregnant, you were 

there for me like a mother is 

supposed to be.” – Cohort 

1 Tribal Grantee Project 

Coordinator 

Increased promotion of positive parenting behaviors and parent–child 

relationships, key predictors of school readiness and achievement. 

Longitudinal studies show that AIAN children often fall behind their peers 

across developmental domains at kindergarten entry, gaps that persist through 

elementary school (Demmert et al., 2006). Promotion of family environments 

that support children’s learning and development helps close these early 

achievement gaps (National Research Council & Institute of Medicine, 2000). 

Performance measures for supportive parenting behaviors and healthy parent– 

child relationships improved (69 percent, n = 9). The promotion of supportive 

learning environments requires an understanding of and respect for different 

cultural beliefs and priorities about parenting behaviors. A lack of culturally 

relevant tools for assessing supportive parenting behaviors initially presented 

a challenge to some tribal grantees. Grantees demonstrated flexibility and 

determination to overcome this challenge, taking the time to identify and use 

more culturally relevant tools, which often required training home visitors to 

implement newly identified assessment instruments. 
78 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

LESSONS FROM THE FIELD 

Home visitors can be a vital source of social support for young pregnant women. 

“Home visitors are there and they’re stepping in and filling 

a gap for something that is missing in the support system of 

these families. That’s really huge.” – Cohort 1 Tribal Grantee 

Project Coordinator 

Providing social support is one of the most important things home visitors can do, and 

it is not always readily captured in the data. One young mother in a rural community 

had been in and out of the foster care system, leaving her with few social supports. Her 

grandmother, the only relative to whom she was connected, was unable to leave the 

house to attend doctor appointments or participate in other pregnancy-related activities. 

The home visitor was able to step in and support this mom throughout her pregnancy by 

consistently being there—by showing up. 

Increased parent knowledge of child development and a child’s developmental 

progress, a foundational step in promoting attentive and responsive parenting 

behaviors. Increased parent knowledge of children’s developmental transitions 

and needs promotes supportive parenting behaviors that help children reach 

their full potential (Sanders & Morawska, 2014). 

A majority of grantees (77 percent, n = 10) improved parents’ knowledge of 

child development and their children’s developmental progress improved 

(77 percent, n = 10). Grantees helped parents and communities recognize 

the tremendous amount of learning and development that takes place before 

kindergarten entry (See Lesson From the Field below). This concept was fairly 

new to some communities. Grantees worked with communities and tribal 

leaders to heighten their awareness of the importance of early learning and 

development. 

Increased child screening rates in key developmental domains. Early 

identification of developmental delays and disabilities is critical to the well-being 

of children and families (American Academy of Pediatrics, 2009). It is estimated 

that only 20 to 30 percent of children with delays or disabilities are identified 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 79

before entering school. Early identification and 

intervention significantly improves developmental 

outcomes (American Academy of Pediatrics, 2009). 

Grantees completed child screenings across multiple 

developmental domains, from children’s general 

cognitive skills to physical health and development. 

Between 46 and 62 percent of grantees 

improved child screening rates, depending on the 

developmental domain under consideration. During 

FY 2012 through FY 2014, nine grantees with similar performance measures 

screened an average of 51 percent of eligible children across developmental 

domains. This rate is well above the national average of 31 percent for child 

screenings in 2011 to 2012 (Child and Adolescent Health Measurement Initiative, 

no date). Despite various challenges, above-average screening rates were 

achieved, including coordinating with other community agencies to prevent 

duplicate child screenings and overcoming initial family resistance. 

“Initially the child screenings 

were a bit of a struggle. There 

was a resistance to assessing 

children and screening children 

for developmental issues. It 

was a bit of a sensitive issue 

in the community.” - Cohort 1 

Tribal Grantee Evaluator

LESSONS FROM THE FIELD

Home visiting programs raise community knowledge about child development.

A major success of the program is spreading “the idea that 

parenting is something that you would think about and 

set goals for and strive toward as opposed to being just 

a reaction to a crying baby. It’s moving that whole idea 

forward that you can plan to have a harmonious day with 

your young children and for yourself.” – Cohort 1 Tribal 

Grantee Program Coordinator

Many programs described child development as a new concept in their communities 

and highlighted the importance of introducing the concept more generally. Home 

visitors work with community members to explain the importance of this critical 

stage of child development. This effort has the potential for larger scale community 

impact.
80 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Table 9-5. At a Glance: Grantee Improvement in School Readiness 

and Achievement (N = 13) 

Construct 

Sample Performance Measures 

Grantees Improved 

% (n) 

Parent Emotional Well-Being or Parenting Stress 

Assessment of parent health status, stress level, or depression 

92 (12) 

Parent Knowledge of Child Development and Their Child’s Developmental Progress 

Parent global knowledge of child development or program provision of information on 

child’s development 

77 (10) 

Parenting Behaviors and Parent–Child Relationship 

Quality of parenting behaviors or parent–child relationship 

69 (9) 

Child Communication, Language, and Emergent Literacy 

Completion of child screening by specified time point or receipt of necessary referral; 

assessment of developmentally appropriate child communication skills 

62 (8) 

Child’s General Cognitive Skills 

Completion of child screening by specified time point or receipt of necessary referral; 

assessment of developmentally appropriate child problem-solving skills 

62 (8) 

Child Physical Health and Development 

Completion of child screening by specified time point or receipt of necessary referral; 

assessment of developmentally appropriate fine and gross motor development 

54 (7) 

Child’s Positive Approaches to Learning 

Completion of child screening by specified time point or receipt of necessary referral 

54 (7) 

Parent Support for Children’s Learning and Development 

Quality and quantity of parent support for children’s learning and development 

54 (7) 

Child’s Social Behavior, Emotional Regulation, and Emotional Well-Being 

Completion of child screening by specified time point or receipt of necessary referral; 

assessment of developmentally appropriate child social-emotional development 

46 (6) 

Safe and Healthy Families: Crime or Domestic Violence 

This benchmark area measures aspects of safe and healthy family functioning to 

support positive developmental trajectories. Grantees had a choice of measuring 

constructs related to either crime or domestic violence. All chose measures of 

domestic violence. These constructs include domestic violence screening and 

provision of support when domestic violence is present. 

Grantee Improvements in Domestic Violence 

Increased screenings for domestic violence. Children exposed to domestic violence 

display behavioral problems and have a significantly higher risk of becoming victims 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 81 

of domestic violence later in life (Yates et al., 2003; Ehrensaft et al., 2003). Given the 

high prevalence of domestic violence in AIAN communities, with 39 percent of AIAN 

women reporting incidents of domestic violence, screening is an important first step 

in identifying families in need of extra resources and support (CDC, 2008). 

A little over half of grantees (54 percent, n = 7) improved screening rates for 

domestic violence. During FY 2012 through FY 2014, 10 grantees with similar 

performance measures screened 59 percent of eligible families for domestic 

violence. Several strategies were used to 

effectively initiate conversations about domestic 

violence and provide support to families when 

domestic violence was present. For example, 

data collection timelines were developed that 

allowed time for relationships to develop between 

families and home visitors before broaching the 

topic. Home visitors often struggled to administer 

domestic violence screening tools, but training increased their confidence, skills, 

and comfort levels with the instruments. Some grantees experienced gaps in 

completing domestic violence screenings as they transitioned to new screening 

tools that worked better for their program staff and participants. 

“A home visitor is not going to use 

a screening tool if they don’t feel 

comfortable with it. If they aren’t 

comfortable, then families aren’t 

comfortable.” – Cohort 1 Tribal 

Grantee Evaluation Specialist 

Increased support for families when domestic violence is present. Social 

support, similar to the support provided by home visitors, reduces the negative 

impact of domestic violence on victims’ mental health and promotes healthy child 

development (Coker et al., 2002). 

Most grantees (69 percent, n = 9) increased their ability to successfully link 

families with resources for domestic violence through referrals and development 

of safety plans. 

Table 9-6. At a Glance: Grantee Improvement in Domestic Violence (N = 13) 

Construct 

Sample Performance Measures 

Grantees Improved 

% (n) 

Of Families Identified for Presence of Domestic Violence, Referrals Made to 

Relevant Services 

Percentage of participants who receive necessary referral 

69 (9) 

Of Families Identified for Presence of Domestic Violence, Families for Which a 

Safety Plan Was Completed 

Percentage of families requiring a safety plan that completed the safety plan 

69 (9) 

Screening for Domestic Violence 

Percentage of women screened for domestic violence 

54 (7) 
82 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Increased Resiliency: Family Economic Self-Sufficiency 

This benchmark area measures important aspects of family economic selfsufficiency. It includes constructs of household income, adult employment and 

education, and adult and child health insurance status. Supporting economic selfsufficiency promotes strong and resilient families that provide ongoing returns 

on program investments, both in economic terms and human capital (See Lesson 

From the Field below). 

LESSONS FROM THE FIELD 

Home visitors support the family’s financial management skills. 

“The home visitor went in and said, ‘Let’s do budgeting.’ 

They sat down and did budgeting, and they learned how to 

do the checkbook and how to pay the bills and how to follow 

their budget, and now they have a new home.” – Cohort 1 

Tribal Grantee Project Coordinator 

Most families enrolled in the Tribal Home Visiting Program experience economic 

hardship that can make managing finances practically and emotionally difficult. Home 

visitors work creatively to support families in taking steps to improve their financial 

situation. They also help parents identify their goals, which may be to enroll in school, 

get a new job, or save money to get a home, and they work with families to break down 

the steps they need to take to achieve these goals. 

Grantee Improvements in Family Economic Self-Sufficiency 

Increased number of adults and children with health insurance. Individuals 

with health insurance tend to access more necessary health care services, such 

as preventive health care, in a timelier manner (Bovbjerg & Hadley, 2007). 

Additionally, health insurance coverage is associated with more positive healthrelated outcomes and reduced financial burdens for patients (Bovbjerg & Hadley, 

2007). 

Almost all grantees (85 percent, n = 11) saw increased rates of adults and children 

with health insurance. During FY 2012 through FY 2014, a majority of eligible 

mothers and children (86 percent) from six grantees with similar performance 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 83 

measures had health insurance within 12 months of enrollment. These increases 

occurred despite some participants choosing to access health care through the 

Indian Health Service rather than purchase health insurance. In some grantee 

communities, families spend less money using the health care services provided 

by Indian Health Service than they would if they purchased insurance. 

Improvements in participant income. Economic resources affect children’s 

cognitive performance, primarily through their influence on parenting quality. 

Reduced economic strain supports parents’ emotional well-being and positive 

parenting behaviors (McLoyd et al., 1994). Researchers have found that the 

effects of family economic resources on child cognitive outcomes are mediated 

by parenting quality (Lugo-Gil & Tamis-LeMonda, 2008). 

Most grantees (69 percent, n = 9) either improved 

family incomes or decreased family economic strain; 

however, improvements were modest. During FY 2012 

through FY 2014, 19 percent of eligible families from 

the five grantees with similar performance measures 

increased their income and benefits. These modest 

gains reflect the economic hardships experienced 

throughout much of Indian Country. Importantly, this 

construct was measured through participant self-reports 

of economic strain. In some cases, the self-reports did 

not fully capture the extent of economic strain families faced. This finding was 

most notable in communities with high concentrations of economic strain, since 

concepts of economic difficulty are relative to individual family perspectives and 

experiences. Additionally, while these improvements are notable, they likely 

underrepresent the steps many families are taking toward greater economic selfsufficiency. 

“Families might have 

different perspectives of 

economic strain. The reality 

is, you don’t see a lot of 

wealth here. So, you don’t 

have a mindset that you 

might be poor or working 

poor. Everyone else is in the 

exact same boat.” – Cohort 1 

Tribal Grantee Evaluator 

Increased adult employment or education. Compared with parents who have 

less education, parents with more education spend more time engaging in 

positive parenting practices to promote children’s learning (Carneiro et al., 2013). 

Parents’ upward mobility can strengthen parental structuring of cognitively and 

linguistically stimulating home environments (Fuller et al., 2015). 

Increases in adult participant education or employment was measured in the 

majority (62 percent, n = 8) of participants. Home visitors worked closely with 

parents to meet individual goals, such as increasing employment hours, returning 

to school, or enrolling in a training program. Grantees noted that sometimes even 

small steps toward improved education would benefit children in the long term. 
84 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Table 9-7. At a Glance: Grantee Improvement in Family Economic 

Self-Sufficiency (N = 13) 

Construct 

Sample Performance Measures 

Grantees Improved 

% (n) 

Health Insurance Status of Participating Adults and Children 

Mothers and children, households, or mothers with health insurance 

85 (11) 

Household Income 

Income among household members, family members, caregivers, 

or mothers; level of perceived economic strain 

69 (9) 

Employment or Education of Participating Adults 

Adult participant enrollment in educational programs; educational 

attainment; adult participant employment, paid hours worked, paid 

plus unpaid hours for child care, or referrals for unemployed mothers 

62 (8) 

Strengthening Systems of Care: Coordination and Referrals 

for Other Community Resources and Supports 

This benchmark area measures program improvements related to strengthening 

systems of care and support for families with young children. It includes 

constructs on identifying family needs, linking families to community resources, 

and sharing information with other community agencies. 

Grantee Improvements in Coordination and Referrals

for Other Community Resources and Supports 

Increased screening and referrals for necessary services. Community 

collaborations enhance program implementation by connecting families with 

other community resources and supports (Durlak & DuPre, 2008; Daro, 2009). 

This coordination is especially important in programs serving at-risk populations 

who require services beyond the expertise of a single program or home visitor. 

Just over half of grantees (54 percent, n = 7) improved completion rates for 

targeted or comprehensive screenings to identify family needs. During FY 2012 

through FY 2014, nine grantees with similar performance measures screened 70 

percent of eligible families to identify needs for services. A majority of grantees 

(77 percent, n = 10) also improved referral rates for families that required 

services. During FY 2012 through FY 2014, 11 grantees with similar performance 

measures gave referrals to 75 percent of eligible families. Slightly over half of 

grantees (54 percent, n = 7) improved completion rates for referrals. During 

FY 2012 through FY 2014, 66 percent of families from 10 grantees with similar 
 

FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 85 

performance measures accessed necessary services. The types of services 

needed and referrals made were tracked, which helped identify high-priority 

needs among families and gaps in available community resources. For example, 

one grantee discussed the high proportion of families in need of basic resources 

(See Lesson from the Field below), such as food or housing support and a lack of 

community resources to effectively respond to this need. 

LESSONS FROM THE FIELD 

Home visiting programs can respond quickly and with flexibility to meet family needs. 

In addition to making the referrals tracked in the data, many home visiting programs 

provide other basic need referrals. One enrolled father left a voicemail thanking his 

home visitor for connecting him to the local emergency food bank. With this connection, 

he was able to provide for his two little girls, which gave him a chance to put effort into 

finding a job. Now that the father is employed, the home visitor noticed that 

the girls “are doing extraordinarily well. Their behavior 

just improved dramatically. Getting them connected 

with services and noticing small things such as vitamin D 

deficiency, just those little things that get overlooked.” 

– Cohort 1 Tribal Grantee Program Coordinator 

Improved collaboration and information sharing with other community 

agencies. Interagency collaboration and information sharing promotes a 

system of coordinated and responsive services for families and young children, 

preventing service duplication and increasing accessibility (Cheminais, 2009). 

Additionally, agency collaborations heighten staff awareness of other community 

services and promote a shared sense of purpose among service providers. 

Almost all grantees (92 percent, n = 12) improved information sharing and 

collaborations with other community agencies. Grantees worked extensively with 

other community agencies to coordinate services to more effectively meet family 

needs. In some communities, the grant facilitated a shift from agencies working 

in silos to working collaboratively to support children and families. Collaboration 

with early intervention service providers was particularly essential. Through 
86 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

partnerships with these providers, children with developmental delays are 

identified earlier and can be directed to services during critical periods of early 

development. For example, one grantee conducts joint home visits with the 

community’s early intervention provider for children needing extra support. 

“I feel like the climate has changed a lot since we first 

started the Tribal Home Visiting Program. People used to 

operate in silos and now we bring all the programs to the 

table and partner to work on things together.” – Cohort 1 

Tribal Grantee Project Coordinator 

In addition, documenting program collaborations helped grantees identify areas 

in need of improvement. For example, one grantee realized a need to improve 

coordination with the tribal dental care program so home visitors could provide 

education on fluoride treatments and connect families to needed dental services. 

This coordination was supported at the federal level as well. ACF funded three 

grantees as they undertook a special initiative known as the Tribal Early Learning 

Initiative (TELI) to increase collaboration across home visiting, child care, and 

Head Start/Early Head Start programs. 

Table 9-8. At a Glance: Grantee Improvement in Coordination and Referrals for 

Other Community Resources and Support (N = 13) 

Construct 

Sample Performance Measures 

Grantees Improved 

% (n) 

Information Sharing: Number of Agencies With Clear Point of Contact in 

Collaborating Community Agency That Includes Regular Sharing of Information 

Number of primary contacts in community agencies or amount of information 

sharing with community agencies 

92 (12) 

Number of Families That Required Services and Received a Referral to Available 

Community Resources 

Number of referrals for families, mothers, mothers and/or children, or caregivers 

and/or household members 

77 (10) 

Number of Families Identified for Necessary Services 

Completion of targeted or comprehensive screening to identify family needs 

54 (7) 

Number of Completed Referrals 

Number of participant self-reports of completion of referral 

54 (7) 

Number of Memoranda of Understanding or Other Formal Agreements With Social 

Service Agencies in the Community 

Number of memoranda of understanding with community agencies 

46 (6) 
FULFILLING THE PROMISE OF THE TRIBAL HOME VISITING PROGRAM 87 

WHY IS IMPROVEMENT IN BENCHMARK 

AREAS IMPORTANT? 

The benchmark areas are designed to measure the activities and outcomes of the 

Tribal Home Visiting Program. Improvements in these areas demonstrate support 

for vulnerable families and ensure a stronger start and more promising future for 

our nation’s youngest children. As supported in the literature and research, these 

benchmark areas are critical in supporting a range of positive child and family 

outcomes. While select home visiting programs were previously implemented in 

tribal communities, the Tribal Home Visiting Program represents the first national 

effort to report on a shared set of benchmark areas, both to monitor program 

improvement and to strengthen the evidence base for home visiting programs 

serving tribal communities. 
This page is intentionally blank. 
   10 FINDINGS, LESSONS

LEARNED, AND

RECOMMENDATIONS 

The Tribal Home Visiting Program provides an invaluable opportunity for 

tribal grantees, ACF, and the broader field to better understand how to serve 

the unique needs of AIAN children and families. The 25 Tribal Home Visiting 

Program grantees have emerged as leaders in the home visiting field, providing 

critical services to some of the most vulnerable AIAN families in the country 

and greatly expanding the reach of home visiting across diverse community 

contexts. Grantees built enormous capacities for implementation of evidencebased practices, data collection, performance measurement, CQI, and rigorous 

evaluation in ways that also meet their individual community needs. They have 

also demonstrated the tremendous potential and abilities of tribal communities 

and organizations when provided with appropriate and timely structural supports. 

Grantees showed that they could meet and exceed high standards for measuring 

family outcomes and demonstrating performance improvements that are 

meaningful to their communities. After four years of intensive and thoughtful 

planning and implementation efforts, the successes and challenges of this effort 

can inform future federal programming and early childhood initiatives in tribal 

communities. 

This chapter summarizes findings from grantee data and experiences, provides 

lessons learned from four years of program planning and implementation, and 

concludes with recommendations for improving the Tribal Home Visiting Program. 

REPORT FINDINGS 

There is much to be gained from the experiences and successes of the 25 

Tribal Home Visiting Program grantees. Each program has built and delivered 

89 
90 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

services in creative ways to fit a unique context. From program data and grantee 

experiences, the following is evident: 

• High-need families were served across diverse community contexts. 

• Program capacity was built to successfully implement and evaluate evidencebased home visiting. 

• Innovative, community-specific strategies were used to overcome challenges. 

• Strong foundations were built for early childhood systems of care. 

After three years of implementation, the performance data of 13 grantees also 

shows that improved program performance was demonstrated. 

Grantees Served High-Need Families Across Diverse

Community Contexts 

Diverse communities were served. Tribal Home Visiting Program grantees 

are diverse in tribal culture, size, location, urbanicity, and degree of previous 

experience with home visiting. Grantees also varied in their selection of 

home visiting models and use of adaptations to those models (see Chapter 6, 

Description of Grantees). Because of this diversity, the most effective way to 

support grantees was through flexible and individualized guidance and TA. 

Families with the greatest needs were served. Services for families experiencing 

a variety of challenges were prioritized. The majority of caregivers served by 

the Tribal Home Visiting Program were of low income, had not attended college, 

and were not currently employed or in school. Many families had experienced 

challenges with substance abuse and child abuse or neglect. 

The reach of home visiting into communities increased. In 2014, 870 families 

were served, over five times the number of families served in 2012. The number 

of home visits provided was increased by more than 17 times in the same 

timeframe. Within a short time period and with limited experience in home 

visiting, grantees served a total of 1,523 unique families, including 1,700 adult 

participants and 1,497 children. These families received nearly 20,000 home 

visits from 2012 to 2014. 

A small fraction of tribal communities and families were served, despite the 

increased reach of home visiting. Over 50 tribal communities are currently 

served, but this is only a small percentage of the 566 federally recognized 

tribal nations and the 37 Urban Indian Centers, tribal consortia, and other 

tribal organizations across the nation (Westat, 2014). Additionally, the 2,697 
 

FINDINGS, LESSONS LEARNED, AND RECOMMENDATIONS 91 

adults and children served represent less than one percent of the 5.2 million 

individuals who identify as American Indian and Alaska Native (Norris et al., 

2012). 

Grantees Built Program Capacity to Successfully Implement

Evidence-Based Home Visiting 

Programs participated in extensive planning efforts to ensure success. 

Grantees thoughtfully planned and executed a multiphase effort to build quality 

home visiting programs. A community needs assessment was conducted, 

and a home visiting model was selected to fit the needs. Grantees reviewed 

and accessed existing resources, and sometimes created new supports to 

prepare to launch the new programs. Prior to program implementation, staffs 

were trained and hired; and implementation, performance measurement, 

and evaluation plans were developed. Data systems were also developed 

or adapted. During initial implementation, policies and procedures were 

developed to support their home visitors, started collecting and monitoring 

benchmark data, and started using their data systems to regularly generate 

reports for CQI. 

Extensive TA on implementation and evaluation was provided. Throughout 

the planning and implementation phases, grantees received support through 

substantial federal involvement and investment as well as intensive TA in program 

issues and evaluation. TA was received from home visiting model developers, 

PATH, and TEI (see Chapter 8, Technical Assistance Provided). Training and 

support were also pursued from other organizations on specific needs, such as 

motivational interviewing, supervision, and domestic violence. 

Substantial capacity for performance measurement and evaluation was 

developed. Through federal investment and intensive technical assistance, 

a unique set of performance measures based on what was most meaningful 

and relevant to community and families was selected and developed. The 

grantees created community advisory groups to provide appropriate oversight 

and feedback during the development process. During this planning process, 

each grantee weighed a number of fundamental factors: whether the selected 

measure fit within its community and cultural context, whether the measure 

aligned with other aspects of its service delivery setting, and whether relevant 

services were available in its community. In addition, consideration had to be 

given as to whether the data collection for a given measure would be overly 

burdensome for participants or home visitors. Addressing these concerns, 

motivated grantees to make critical assessments and analyses and prompted 
92 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

insights that extend beyond the work on the home visiting program. Many 

grantees shared that the benchmark development process fostered broader tribal 

capacity and contributed to a better understanding of the value of thoughtful, 

systematic measurement. 

Each grantee also developed and implemented rigorous program evaluations. 

During this process, grantees considered program goals, community expectations 

and priorities, and federal requirements to create evaluations that were both 

locally meaningful and informative to the broader home visiting field. The 

original Tribal HomVEE report (Del Grosso et al., 2011) noted, “the research 

literature for home visiting in tribal communities is in its infancy” (p. 28). That 

report recommended a number of specific efforts for planning, adopting, 

sustaining, and evaluating tribal home visiting programs, including developing 

model specification and documentation, creating fidelity standards and measures, 

designing research on the feasibility of implementation, and making model 

adaptations. Over the past four years, Tribal Home Visiting Program grantees 

have made enormous strides toward addressing some of these efforts. Program 

evaluations will be completed, and final evaluation reports will be compiled over 

the next two years. 

Absence of assessment measures validated in tribal communities was 

challenging. Grantees consistently struggled with a lack of screening and 

assessment instruments that had been validated for use with AIAN children or 

families. When identifying potential tools for screening and assessing families, 

grantees noted a lack of tools that had been rigorously validated in tribal settings. 

To respond to this challenge, grantees drew on the experience of the Tribal 

Early Childhood Research Center to determine if there had been any previous 

work with the measure in similar communities that may not have been noted 

in published research. In addition, grantees carefully examined tools with 

community members to identify any items that may not be appropriate within 

their particular setting. 

Increased capacity supported tribal and organizational decision-making. The 

growth in program capacity to implement and assess evidence-based home 

visiting services will serve grantees as they seek to continue and expand early 

childhood interventions within their communities. While most grantees 

entered the Tribal Home Visiting Program without experience implementing 

home visiting services, all 25 now have extensive experience educating 

community members and leadership on a variety of topics that support 

decision-making and sustainability. These topics include the benefits of home 

visiting services and the value of developing data collection protocols and 
FINDINGS, LESSONS LEARNED, AND RECOMMENDATIONS 93 

performance measures. As a result of this increased program capacity, tribal 

communities are now more informed and better positioned to advocate for and 

serve children and families. 

Grantees Used Innovative, Community-Specific Strategies

to Overcome Challenges 

Innovative strategies were used for serving AIAN families. A variety of creative 

strategies that are responsive to family needs and supported by community 

practices and values (See Lesson From the Field below) were used. Among 

many other innovations, grantee programs involved elders and community 

members in decision making, as program staff and advocates for the home 

visiting program. Through strategic group outreach activities, community 

awareness was also raised about child development topics and the array of 

services available. In order to better understand and develop an appropriate 

engagement approach to fit participant needs, grantees engaged in careful 

assessment of the current and historical challenges relevant to each potential 

participant group or tribal community focusing on respect for local customs and 

norms. 

LESSONS FROM THE FIELD 

The addition of group support often enhances home visiting services in tribal settings. 

“For a lot of families that I work with, a big component is 

working through what their childhood experiences were like 

and making a concerted effort to have them be different 

for their children—just reconciling a lot of that past trauma 

and figuring out how to do it differently for their kids.” 

– Cohort 1 Tribal Grantee Program Coordinator 

Home visiting can provide the necessary space for some parents to discuss the 

emotional suffering that may affect their own parenting. Many grantees use program 

funds to support supplementary programs such as Circles of Security or Positive Indian 

Parenting to directly address this issue. One grantee expressed that this piece is 

integral to improving the parent–child relationships in the families they serve. 
94 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Community-specific adaptations to home visiting models were developed and 

implemented. Most grantees incorporated some cultural adaptations or other 

enhancements to their selected models, which included incorporating traditional 

parenting practices, Native language, and cultural norms on successful child 

development. 

These adaptations reflect the substantial adaptive strengths of tribal communities 

to identify and target culturally appropriate enhancements suited to their 

communities; however, they also reflect the challenge in establishing the 

effectiveness of additional home visiting models for AIAN populations. Another 

challenge on the topic of home visiting adaptations is the dearth of research 

evidence to inform and support rigorous measurement of cultural enhancements 

in a manner that will support replication. 

Recruitment and retention challenges are being addressed. Grantees recognize 

and are intimately aware of the particular characteristics of the communities 

and families they serve. One major ongoing challenge is recruiting and retaining 

participants and families. For many AIAN families in both urban and rural areas, 

normal lifestyle patterns involve transitions between various locations throughout 

the year. Sometimes families travel between reservation land and cities or 

towns, or from villages to hunting or fishing camp settings to gather resources for 

subsistence and trade. Tribal Home Visiting Program grantees have respect for 

these cultural practices and contexts and make accommodations to home visiting 

model standards, such as the timing of participant contacts and scheduling of 

home visits. 

In addition, grantees served some of the most vulnerable and high-risk 

families in their communities by addressing participants’ immediate needs 

(such as transportation to treatment appointments, child welfare visitation, 

and visits to incarcerated parents) and by being flexible in arranging locations 

for home visits. The challenge of reaching and serving families and children 

with the greatest needs in the communities has been more than met. The 

grantees will draw upon the breadth of outreach and engagement experience 

gained over the past four years to continue to provide these essential services 

in the future. 

Grantees Built Strong Foundations for Early Childhood

Systems of Care 

Coordination of early childhood systems was strengthened. Collaborative 

relationships, partnerships, and referral networks that represent a solid 
 

FINDINGS, LESSONS LEARNED, AND RECOMMENDATIONS 95 

early childhood system infrastructure have been established. By leading a 

community needs assessment and undertaking program outreach efforts early 

in implementation, grantees are now more aware of other service providers. 

Likewise, those programs are more aware of the benefits of home visiting. 

Community partners are incorporated into community advisory boards and in 

some cases are providing coordinated services to families. 

Programs have embraced “systems thinking” for the benefit of the families. 

Service duplication is being reduced, and the ability of the community 

programs to meet family needs across the prenatal-to-school continuum 

is being maximized. One of the exciting parts of the Tribal Home Visiting 

Program is the Tribal Early Learning Initiative, a partnership between ACF and 

four grantees that are collaborating across home visiting, child care, and Head 

Start/Early Head Start programs. While these sites have been innovators in 

early childhood systems building in tribal communities, many grantees have 

built coalitions and transformed how their communities approach services 

to young children and their families. Home visitors often work beyond early 

childhood systems to advocate for their families (See Lessons From the Field 

below). 

LESSONS FROM THE FIELD 

Using “systems thinking” helps families increase self-sufficiency. 

“We just had another one of our moms get a driver’s 

license. I saw the proud picture about two weeks ago. In 

our area, transportation is such an issue; having a driver’s 

license and a vehicle, it’s pretty critical. It’s life changing.” 

– Cohort 1 Tribal Grantee Evaluator 

Transportation is a consistent challenge faced by most of the grantees. One program 

realized that many of the enrolled mothers and fathers did not have a driver’s license 

because of outstanding fines. Program staff supported these individuals in writing 

letters to the Superior Court to ask for forgiveness or community service hours. In 

going beyond typical home visiting services, the program helped enrollees regain their 

licenses and learn new skills in interacting with the legal system. 
96 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Evidence of Progress: Grantees Improved Program Performance 

Tribal grantees successfully implemented new home visiting programs within 

their communities and saw substantial performance improvement across all 

six legislatively mandated performance areas in a limited time period. Some 

successes from each domain are highlighted below. 

Overall Program Improvement. A majority (77 percent) of the 13 Cohort 1 

grantees demonstrated overall improvement in the benchmark areas in the threeyear period. 

Maternal and Newborn Health. Almost all grantees (92 percent) increased 

the health care utilization of children and mothers, while 77 percent improved 

maternal depression screenings and the receipt of timely or adequate prenatal 

care for pregnant mothers. Additionally, 62 percent saw improvements in 

breastfeeding. Family progress towards improved maternal and newborn health 

was encouraged. Given the short timelines for demonstrating improvement in 

family outcomes, family progress toward larger and more quantifiable outcomes 

is important to consider. Specifically, many family outcomes depend on changing 

complex behaviors that require time and a process of interim steps to achieve 

desired changes. While most grantees (69 percent) improved measures of 

parental use of alcohol, tobacco, and illicit drugs, others saw families taking 

important steps toward improvement. For example, one grantee did not see a 

reduction in the number of caregivers who smoked but saw a reduction in the 

number of cigarettes smoked per day, which represents a major step toward a 

larger change. 

Child Injuries; Abuse, Neglect, or Maltreatment; and Emergency Department 

Visits. Almost all grantees (92 percent) saw decreases in the number of children 

who are first-time victims of maltreatment and the number of substantiated 

reports of children being victims to maltreatment. Fifty-four percent saw a 

reduction in visits for children to the emergency room, and 39 percent saw a 

reduction for mothers. 

School Readiness and Achievement. There was a 77 percent improvement 

on measures of parent knowledge of child development, and 69 percent on 

measures of parenting behaviors and parent–child relationships. In addition, 

there was an improvement in screening rates for developmental delays: general 

cognitive skills (61 percent), positive approaches to learning (54 percent), and 

physical health and development (54 percent). 
FINDINGS, LESSONS LEARNED, AND RECOMMENDATIONS 97 

Domestic Violence. Fifty-four percent of grantees improved on their screening 

for domestic violence, while 69 percent saw increases in safety plan completion 

for families experiencing domestic violence. 

Family Economic Self-Sufficiency. A majority of grantees (85 percent) saw 

increases in the number of adults and children with health insurance; 69 percent 

saw improvements in the household income of families in their program; and 62 

percent saw increased adult participant education or employment. 

Coordination and Referrals for Other Community Resources and Supports. 

Almost all (92 percent) of grantees improved on measures related to regular 

information sharing with community agencies, and 77 percent increased the 

number of families receiving referrals to available community resources. 

LESSONS LEARNED 

The lessons learned from implementing the Tribal Home Visiting Program for four 

years can hopefully guide ACF in the continued support of AIAN children, families, 

and communities. 

Tribal Communities Can Meet and Exceed the Federal Home 

Visiting Program’s High Expectations 

The Tribal Home Visiting Program grantees demonstrated that tribal communities 

are capable of meeting the high standards and expectations of the Federal Home 

Visiting Program with respect to collecting and using data and demonstrating 

performance improvements. The legislation gave HHS the flexibility to align 

the requirements for the tribal program with the requirements for the state 

program “to the extent practicable.” ACF and HRSA decided early on that this 

flexibility was important but should be used primarily to ensure that programs 

would be tribally driven and responsive to community needs; they did not want 

this flexibility to simplify or dilute the legislative goal of using and building on 

evidence and data. ACF set high expectations for the grantees and offered 

intensive TA and supports to grantees as they strived to meet them. 

Tribal Grant Programs Are Successful When They Intentionally

Emphasize Relationship Building and Capacity Building 

When working with Native communities, relationships are critical at every 

level—among federal staff, grantees, TA providers, tribal leaders, evaluators, and 

other partners. ACF recognized the importance of relationships, starting with 
98 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

structuring the grants as cooperative agreements. The cooperative agreement 

establishes the project as a partnership between the grantee and the federal 

government and clearly outlines the roles and responsibilities of each partner 

as well as the provision of ongoing assistance through substantial federal 

involvement. Although the cooperative agreement was new to many grantees, it 

has allowed for true relationship building and more intensive capacity building TA 

than is typical for a discretionary grant. 

Some of the successful strategies for relationship building and optimizing TA 

opportunities include monthly calls between ACF, TA providers, and each grantee 

team; site visits conducted by ACF and TA providers at key points during the grant; 

frequent in-person grantee meetings and peer learning opportunities; and virtual 

communities of learning across grantees. Relationships are also important when 

it comes to carrying out grant evaluations and data requirements; grantees that 

have been most successful have fostered strong partnerships across program and 

evaluation staff to build capacity and comfort of all home visiting team members 

with data and evaluation. 

Successful Evidence-Based Initiatives in Tribal Communities Must 

Build on Principles of Implementation Science 

As an evidence-based policy initiative, the Tribal Home Visiting Program builds 

on the idea that broad replication of evidence-based (or promising) home visiting 

models will lead to corresponding impacts for children and families. Recognizing 

that these impacts could only be realized through developing capacity around 

implementation fidelity and quality, ACF based the design of the Tribal Home 

Visiting Program on the principles of implementation science. These principles 

posit that agencies typically progress through a set of common stages when 

implementing new programs and that targeting key drivers at different stages can 

promote fidelity and quality. For example, a key dimension of quality program 

implementation includes initial and ongoing staff support (See Lesson From the 

Field below). The Tribal Home Visiting Program is structured to include a planning 

year in which grantees conducted a needs and readiness assessment. This 

period provided sufficient time for grantees to explore and build the necessary 

infrastructure to carry out the program requirements. Providing specific 

policy guidance to grantees required careful use of the results from the needs 

and readiness assessments in selecting their models and to articulate a clear 

and detailed plan for the installation stage of implementation (including staff 

selection, training, professional development, and supervision) prior to beginning 

services. 
FINDINGS, LESSONS LEARNED, AND RECOMMENDATIONS 99 

LESSONS FROM THE FIELD 

The success of a program often relies on the quality of support provided to the staff. 

Some grantees use formal approaches such as reflective supervision to support 

home visitors. Others use informal gatherings to ensure that home visitors have 

opportunities to process the tough, emotional work they do. 

“There are so many issues that go beyond the routine 

nursing care we provide that right now we are not 

capturing...it’s not just one family that has all these needs, 

it is many, many families, and home visitors bring home 

that burden of asking, ‘Should I have left that mom there, 

did they get fuel, is the house freezing?’” – Cohort 1 Tribal 

Grantee Project Manager 

During initial implementation of home visiting programs and by utilizing 

guidance from model developers and federal partners, grantees developed 

policies and procedures to support home visitors and program staff, started 

collecting and monitoring benchmark data, and started using data systems 

to regularly generate reports for data-based decision making and CQI. TA 

providers have focused the work on building tribal capacity and infrastructure 

for program implementation, data collection, evaluation, and quality 

improvement. An implementation science-based approach has been critical 

to the success of grantees and the program. 

Tribally and Community Driven Programming and Decision

Making Are Key to Promoting Innovation 

Many evidence-based and research-driven initiatives have not acknowledged 

the wishes, capacities, and desires of tribal communities. Too often, initiatives 

have been imposed on rather than driven by tribes. A critical lesson of the Tribal 

Home Visiting Program is the importance of supporting tribe- and communitydriven programming and decision-making. ACF recognized that the program 

implemented by each grantee would only be successful if the tribal community 

“owned” the program. Promoting this level of program ownership was 
100 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

fundamental to grantees’ abilities to develop workable and innovative practice 

solutions tailored to the characteristics of the community, addressing immediate 

family needs, and fostering greater family engagement.

One strategy many grantees felt contributed to their success was to involve 

multiple community stakeholders—tribal leaders, elders, cultural leaders, 

parents, service providers, and other community members—at every stage 

of their projects. The involvement of the community and use of feedback 

loops have benefitted all components of these projects: conducting needs 

assessments, selecting a model, hiring home visitors, meeting family needs, 

selecting benchmarks performance measures, developing and carrying out 

evaluations, and examining and using data to drive improvement. This lesson 

builds on respect for tribal sovereignty as well as a recognition that each tribal 

community is unique in its culture, vision, goals, and strengths. 

Evidence-Based Initiatives in Tribal Communities Can Be 

Strengthened by Support for Adaptation and Enhancement

Successful implementation of evidence-based models (particularly those 

developed for nontribal settings) often requires adaptation or enhancement 

when implemented in an AIAN community. For example, SAMHSA’s Strategic 

Prevention Framework for effective, culturally appropriate and sustainable 

prevention activities describes a step-wise process for embedding best practices 

into the context of the community where the program will be implemented 

(Substance Abuse and Mental Health Services Administration, no date). ACF 

recognized the importance of supporting grantees in developing cultural and 

contextual adaptations. As such, ACF provided intensive programmatic and 

evaluation TA, which included facilitating grantee access to nationally recognized 

experts in research and evaluation with tribal communities.

Grantees designed enhancements and adaptations in partnership with 

community members, tribal and cultural leaders, and other important 

stakeholders. They worked in close partnership with model developers to identify 

the required “core components” of models and those that could be adapted or 

enhanced. When designing these innovations, grantees also considered which 

aspects of the culture or context were most appropriate for integration into the 

home visiting program. The enhancement or adaptation process has often been 

iterative and nonlinear, occurring throughout implementation. This process 

necessitates ongoing and consistent TA that can be flexible and responsive while 

also helping grantees to contribute to the evidence base for effective home 

visiting program adaptations for tribal communities. 
 

FINDINGS, LESSONS LEARNED, AND RECOMMENDATIONS 101 

A Systems-Building Emphasis Is Critical for Strengthening

and Sustaining Tribal Early Childhood Programs 

Congress envisioned the Tribal Home Visiting Program as a systems-building 

initiative. The legislative goals explicitly include the coordination of services for 

at-risk communities and the provision of comprehensive services to families. 

Because the success of home visiting programs depends on connecting families 

to needed assistance and because the families served by home visiting programs 

are likely receiving many health and early childhood services in the community, 

the grantees must ensure that their programs are not operating “in silos.” 

Recognizing this critical component, ACF promoted systems building by requiring 

grantees to conduct a review of existing early childhood system infrastructure in 

their initial planning process. Grantees were required to designate community 

partners with which they would work in concert during the home visiting program 

implementation. ACF also set expectations for collaboration and partnership by 

requiring grantees to monitor ongoing development of agency memoranda of 

understanding and new agency partnership contacts as part of the performance 

measurement plans. This systems building emphasis has fostered ongoing 

grantee partnership efforts that contribute to the long-term sustainability of early 

childhood programming in grantee communities. 

SUMMARY AND RECOMMENDATIONS 

After four years of implementation, ACF recognizes the opportunity to strengthen 

the Tribal Home Visiting program and build on the solid foundation already 

established. Going forward, ACF will maintain high expectations for Tribal 

MIECHV grantees and support their success through continued efforts to develop 

and enhance early childhood systems in tribal communities, improvements to the 

performance measurement and continuous quality improvement system in close 

communication with tribal grantees, and promotion of a learning agenda to build 

knowledge of effective home visiting in tribal communities. 

As exemplified by the Tribal Early Learning Initiative, and demonstrated by the tribal 

home visiting grantees, children and families are served best when collaborative 

relationships, partnerships, and referral networks are established for a solid early 

childhood system infrastructure. ACF will continue to emphasize this priority of 

early childhood systems building as the Tribal Home Visiting program continues. 

As demonstrated in this report, the benchmarks process helped to build the 

capacity of grantees for monitoring the success of their programs. ACF will 
102 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

continue to emphasize efforts to support grantees in using performance 

measurement data to improve programs through modifications to the benchmark 

requirement that facilitate use of the data for continuous quality improvement 

and other priorities. These changes to the benchmarks requirement will be made 

in close communication with grantees, following expert guidance. 

Finally, given the expectations for rigorous evaluation of home visiting in tribal 

communities, the Tribal Home Visiting program has helped to build local and 

tribal capacity for evaluation. ACF will continue to foster local grantee efforts 

to understand their own home visiting programs while supporting efforts to 

generate knowledge to inform the broader field of implementation science 

around adaptation and other important topics 
    REFERENCES
 

Adi-Japha, E., & Klein, P. S. (2009). Relations between parenting quality and 

cognitive performance of children experiencing varying amounts of child care. 

Child Development, 80, 893-906. 

Adirim, T., & Supplee, L. (2013). Overview of the federal home visiting program. 

Pediatrics, 132(Suppl. 2), S59-S64. 

Administration for Children and Families. (2012). Tribal Maternal, Infant, and 

Early Childhood Home Visiting (TMIECHV) Grant Program under the Affordable 

Care Act (ACA). Funding Opportunity HHS-2012-ACF-OCC-TH-0302. Washington, 

DC: U.S. Department of Health and Human Services. Retrieved from http://www.

acf.hhs.gov/grants/open/foa/files/HHS-2012-ACF-OCC-TH-0302_0.pdf 

American Academy of Pediatrics. (2009). Developmental screening in early 

childhood systems: Summary report. Retrieved from http://healthychildcare.org/

pdf/dsecsreport.pdf 

Bagot, R. C., & Meaney, M. J. (2010). Epigenetics and the biological basis of 

gene x environment interactions. Journal of the American Academy of Child and 

Adolescent Psychiatry, 49(8), 752-771. 

Besaw, A., Kalt, J. P., Lee, A., Sethi, J., Boatright-Wilson, J., & Zemler, M. (2004). 

The context and meaning of family strengthening in Indian America. A report to 

the Annie E. Casey Foundation. Baltimore, MD: Annie E. Casey Foundation. 

Bovbjerg, R. R., & Hadley, J. (2007, November). Why health insurance is 

important. Health Policy Briefs, DC-SPG no. 1. Washington, DC: Urban Institute. 

103 
104 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Brave Heart, M. Y. H. (1998). The return to the sacred path: Healing the historical 

trauma response among the Lakota. Smith College Studies in Social Work, 68(3), 

287-305.

Brave Heart, M. Y. H., Chase, J., Elkins, J., & Altschul, D. B. (2011). Historical 

trauma among indigenous peoples of the Americas: Concepts, research, and 

clinical considerations. Journal of Psychoactive Drugs, 43(4), 282-290.

Carneiro, P., Meghir, C., & Parey, M. (2013). Maternal education, home environments, 

and child development. Journal of the European Economic Association, 11(S1), 28-29. 

Centers for Disease Control and Prevention. (2006). A report of the CDC/ATSDR 

Preconception Care Work Group and the Select Panel on Preconception Care.

Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm 

Centers for Disease Control and Prevention. (2008). Adverse health conditions 

and health risk behaviors associated with intimate partner violence—United 

States, 2005. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/

mm5705a1.htm

Centers for Disease Control and Prevention. (2011). CDC health disparities and 

inequalities report—United States, 2011. Morbidity and Mortality Weekly Report, 

60(Suppl.). Retrieved from http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

Centers for Disease Control and Prevention. (2012). National action plan for 

child injury prevention. Atlanta, GA: Centers for Disease Control and Prevention, 

National Center for Injury Prevention and Control. Retrieved from http://www.

cdc.gov/safechild/pdf/National_Action_Plan_for_Child_Injury_Prevention.pdf

Centers for Disease Control and Prevention. (2013). CDC health disparities 

and inequalities report. Morbidity and Mortality Weekly Report, 62(Suppl. 

3). Retrieved from http://www.cdc.gov/mmwr/preview/ind2013_

su.html#HealthDisparities2013

Cheminais, R. (2009). Effective multi-agency partnerships: Putting every child 

matters into practice. Thousand Oaks, CA: Sage.

Child and Adolescent Health Measurement Initiative. (no date). Data Resource 

Center. Retrieved from http://www.childhealthdata.org 

Claessens, A., Engel, M., & Curran, C. F. (2015). The effects of maternal depression 

on child outcomes during the first years of formal schooling. Early Childhood 

Research Quarterly, 32, 80-93.
REFERENCES 105
 

Coker, A. L., Smith, P. H., Thompson, M. P., McKeown, R. E., Bethea, L., & Davis, 

K. E. (2002). Social support protects against the negative effects of partner 

violence on mental health. Journal of Women’s Health & Gender-Based Medicine, 

11(5), 465-476. 

Daro, D. (2006). Home visitation: Assessing progress, managing expectations. 

Chicago, IL: Ounce of Prevention Fund and Chapin Hall Center for Children. 

Daro, D. (2009). Embedding home visitation programs within a system of 

early childhood services. Chapin Hall Issue Brief. Chicago, IL: Chapin Hall at the 

University of Chicago. 

Del Grosso, P., Kleinman, R., Esposito, A. M., Sama Martin, E., & Paulsell, D. 

(2011). Assessing the evidence of effectiveness of home visiting program models 

implemented in tribal communities. Washington, DC: Office of Planning, Research 

and Evaluation, Administration for Children and Families, U.S. Department 

of Health and Human Services. Retrieved from http://homvee.acf.hhs.gov/

TribalReport.pdf 

Demmert, W. G., Grissmer, D., & Towner, J. (2006). A review and analysis of the 

research on Native American students. Journal of American Indian Education, 

45(3), 5-23. 

Doyle, O., Harmon, C. P., Heckman, J. J., & Tremblay, R. E. (2009). Investing in early 

human development: Timing and economic efficiency. Economics and Human 

Biology, 1(6), 1-6. 

Duncan, G. J., Ziol-Guest, K. M., & Kalil, A. (2010). Early-childhood poverty and 

adult attainment, behavior, and health. Child Development, 81(1), 306-325. 

Duran, E., & Duran, B. (1995). Native American postcolonial psychology. Albany, 

NY: State University of New York Press. 

Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research 

on the influence of implementation on program outcomes and the factors 

affecting implementation. American Journal of Community Psychology, 41(3-4), 

327-350. 

Eckstrand, K. L., Ding, Z., Dodge, N. C., Cowan, R. L., Jacobson, J. L., Jacobson, S. 

W., et al. (2012). Persistent dose-dependent changes in brain structure in young 

adults with low-to-moderate alcohol exposure in utero. Alcoholism: Clinical and 

Experimental Research, 36(11), 1892-1902. 
106 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Ehrensaft, M. K., Cohen, P., Brown, J., Smailes, E., Chen, H., & Johnson, J. G. 

(2003). Intergenerational transmission of partner violence: A 20-year prospective 

study. Journal of Consulting and Clinical Psychology, 79(4), 741-753. 

Farran, D. C. (2000). Another decade of intervention for children who are low 

income or disabled: What do we know now? In J. Shonkoff & S. Meisels (Eds.), 

Handbook of early childhood intervention (2nd ed., pp. 510-548). New York, NY: 

Cambridge University Press. 

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., 

et al. (1998). Relationship of childhood abuse and household dysfunction to many 

of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) 

Study. American Journal of Preventive Medicine, 14(4), 245-258. 

Fisher, P. A., & Ball, T. J. (2002). The Indian Family Wellness Project: An application 

of the tribal participatory research model. Prevention Science, 3(3), 235-240. 

Fuller, B., Bein, E., Kim, Y., & Rabe-Hesketh, S. (2015). Differing cognitive 

trajectories of Mexican American toddlers: The role of class, nativity, and 

maternal practices. Hispanic Journal of Behavioral Sciences, 37(2), 139-169. 

Garner, A. S. (2013). Home visiting and the biology of toxic stress: Opportunities 

to address early childhood adversity. Pediatrics, 132(Suppl. 2), 565-573. 

Guterman, N. (2001). Stopping child maltreatment before it starts: Emerging 

horizons in early home visitation services. Thousand Oaks, CA: Sage. 

Hodge, D., Limb, G., & Cross, T. (2009). Moving from colonization toward balance 

and harmony: A Native American perspective on wellness. Social Work, 54(3), 

211-219. 

Home Visiting Evaluation of Evidence. (2014). Home visiting program: Reviewing 

evidence of effectiveness (OPRE Report No. 2014-60). Retrieved from http://

homvee.acf.hhs.gov/HomVEE_brief_2014-60.pdf#Brief1

Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., et al. (2007, April). 

Breastfeeding and maternal and infant health outcomes in developed countries. 

Evidence Report/Technology Assessment No. 153 (AHRQ Publication No. 07-

E007). Rockville, MD: Agency for Healthcare Research and Quality. 

James Bell Associates. (2012). Design options for home visiting evaluation: 

Evaluation technical assistance brief. Arlington, VA: Lance Till and Lauren Supplee. 
REFERENCES 107
 

Karoly, L. A., Kilburn, M. R., & Cannon, J. S. (2005). Early childhood interventions: 

Proven results, future promise. Santa Monica, CA: RAND Corporation. 

King, M., Smith, A., & Gracey, M. (2009). Indigenous Health Part 2: The underlying 

causes of the health gap. Lancet, 374(9683), 76-85. 

Krech, P. R. (2002). Envisioning a healthy future: A re-becoming of Native 

American men. Journal of Sociology and Social Welfare, 29(1), 77-95. 

Lawrence, J. S. (1993). Significant benefits: The High/Scope Perry Preschool Study 

through age 27. Ypsilanti, MI: High/Scope Press. 

Limb, G., Shafer, K., & Sandoval, K. (2012). The impact of kin support on urban 

American Indian families. Child & Family Social Work, 19(4), 432-442. 

Lugo-Gil, J., & Tamis-LeMonda, C. S. (2008). Family resources and parenting 

quality: Links to children’s cognitive development across the first 3 years. Child 

Development, 79(4), 1065-1085. 

Mannes, M. (1995). Factors and events leading to the passage of the Indian Child 

Welfare Act. Child Welfare, 74(1), 264-282. 

McLoyd, V. (1998). Socioeconomic disadvantage and child development. American 

Psychologist, 53, 185-204. 

Mraz Esposito, A., Del Grosso, P., Kleinman, R., Sama-Miller, E., & Paulsell, D. 

(2014). Assessing the evidence of effectiveness of home visiting program models 

implemented in tribal communities. Washington, DC: Office of Planning, Research 

and Evaluation, Administration for Children and Families, U.S. Department of 

Health and Human Services. Retrieved from http://homvee.acf.hhs.gov/HomVEE_

Tribal_Report_2014-57.pdf#tribal_report 

National Research Council & Institute of Medicine. (2000). From neurons to 

neighborhoods: The science of early childhood development. Washington, DC: 

National Academy Press. 

Norris, T., Vines, P. L., & Hoeffel, E. M. (2012). The American Indian and Alaska 

Native Population: 2010 census brief. U.S. Census Bureau. Retrieved from http://

www.census.gov/prod/cen2010/briefs/c2010br-10.pdf. 

Olfson, M., Marcus, S. C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H. A. 

(2002). National trends in the outpatient treatment of depression. Journal of the 

American Medical Association, 287(2), 203–209. 
108 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Pew Center on the States. (2011). Policy framework to strengthen home 

visiting programs. Washington, DC: Author. Retrieved from: http://

www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2011/

HomeVisitingmodelpolicyframeworkpdf.pdf?la=en 

Raikes, H., Green, B. L., Atwater, J., Kisker, E., Constantine, J., & Chazan-Cohen, 

R. (2006). Involvement in Early Head Start home visiting services: Demographic 

predictors and relations to child and parent outcomes. Early Childhood Research 

Quarterly, 21, 2-24. 

Red Horse, J. (1997). Traditional American Indian family systems. Families, 

Systems, & Health, 15(3), 243-250. 

Red Horse, J. G., Lewis, R., Feit, M., & Decker, J. (1978). Family behavior of urban 

American Indians. Social Casework, 59(2), 67-72. 

Reynolds, A., Temple, J., Robertson, D., & Mann, E. (2001). Long-term effects of 

an early childhood intervention on educational achievement and juvenile arrest: 

A 15-year follow-up of low income children in public schools. Journal of the 

American Medical Association, 285(18), 2339-2346. 

Sanders, M. R., & Morawska, A. (2014). Can changing parental knowledge, 

dysfunctional expectations and attributions, and emotion regulation improve 

outcomes for children? Encyclopedia on Early Childhood Development, 3rd ed. 

Satterfield, D., Burd, C., Valdez, L., Hosey, G., & Eagle Shield, J. (2002). The “inbetween people”: Participation of community health representatives in diabetes 

prevention and care in American Indian and Alaska Native communities. Journal 

of Health Promotion and Practice, 3(2), 166-175. 

Schweinhart, L. L., Montie, J., Xiang, Z., Barnett, W. S., Belfield, C. R., & Nores, 

M. (2004). The High/Scope Perry Preschool Study through age 40: Summary, 

conclusions and frequently asked questions. Ypsilanti, MI: High/Scope Educational 

Research Foundation. 

Shonkoff, J. P., Garner, A. S., Committee on Psychological Aspects of Child and 

Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & 

Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects 

of childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. 

Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health 

systems and health. The Milbank Quarterly, 83(3), 457-502. 
REFERENCES 109

Substance Abuse and Mental Health Services Administration. (no date) Strategic 

prevention framework. Washington D.C.: Author. Retrieved from: http://www.

samhsa.gov/spf.

Tews, D. S., Sherry, M. K., Butler, J. A., & Martin, A. (2008, February). Embracing 

quality in local public health: Michigan’s quality improvement guidebook. 

Michigan Local Public Health Accreditation Program, Multi-State Learning 

Collaborative 2. Retrieved from https://accreditation.localhealth.net/

Thompson, R. A. (2008). Measure twice, cut once: Attachment theory and the 

NICHD study of early child care and youth development. Attachment & Human 

Development, 10, 287-297.

Tribal Evaluation Workgroup. (2013, September). A roadmap for collaborative and 

effective evaluation in tribal communities. Washington, DC: Children’s Bureau, 

Administration for Children and Families, U.S. Department of Health and Human 

Services. 

Unger, S. (1977). The destruction of American Indian families. New York, NY: 

Association of American Indian Affairs. 

U.S. Department of Health and Human Services. (2007). National Child Abuse and 

Neglect Data System.

U.S. Department of Health and Human Services, Administration for Children 

and Families, Office of Child Care. (2014). Home visiting programs in tribal 

communities: Their implementation stories. Retrieved from http://www.acf.hhs.

gov/programs/ecd/programs/home-visiting

U.S. Department of Health and Human Services, Administration for Children and 

Families. (no date). An introduction to the Tribal Home Visiting Program. Retrieved 

from https://www.acf.hhs.gov/sites/default/files/ecd/practice_brief_02_18_15.pdf

U.S. Department of Health and Human Services, Administration for Children and 

Families. (no date). Home visiting evidence of effectiveness: Models. Retrieved 

from http://homvee.acf.hhs.gov/Models.aspx

U.S. Department of Health and Human Services, Administration for Children 

and Families, Office of Child Care. (no date). Guidance for submitting a needs 

assessment and plan for responding to identified needs (Phase 2 implementation 

plan) Cohort 3 grantees. Retrieved from http://www.acf.hhs.gov/sites/default/files/

occ/tribal_hv_implementation_plan_guidance_cohort_3_revised_final_508.pdf
110 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Victora, C. G., Horta, L. B., de Mola, C. L., Quevedo, L., Pinheiro, R. T., Gigante, D. 

P., et al. (2015). Association between breastfeeding and intelligence, educational 

attainment, and income at 30 years: A prospective birth cohort study from Brazil. 

Lancet Global Health, 3(4), e199-e205. 

Walls, M. L., Johnson, K. D., Whitbeck, L. B., & Hoyt, D. R. (2006). Mental health 

and substance abuse services preferences among American Indian people of the 

Northern Midwest. Community Mental Health Journal, 42(6), 521-535. 

Wagner, M. M., Spiker, D., Hernandez, F., Song, J., & Gerlach-Downie, S. G. (2001). 

Multisite Parents as Teachers evaluation: Experiences and outcomes for children 

and families. Menlo Park, CA: SRI International. 

Westat. (2014). Understanding urban Indians’ interactions with ACF programs and 

services. OPRE Report 2014-40. Washington, DC: Office of Planning, Research and 

Evaluation, Administration for Children and Families, U.S. Department of Health 

and Human Services. Retrieved from http://www.acf.hhs.gov/sites/default/files/

opre/urban_indians_report.pdf 

Whitbeck, L. B. (2006). Some Guiding Assumptions and a Theoretical Model 

for Developing Culturally Specific Preventions with Native American People. 

Sociology Department, Faculty Publications. Paper 27. http://digitalcommons.unl.

edu/sociologyfacpub/27. 

World Health Organization. (2004). The importance of caregiver-child interactions 

for the survival and healthy development of young children: A review. Retrieved 

from http://whqlibdoc.who.int/publications/2004/924159134X.pdf 

Yates, T., Dodds, M., Sroufe, A., & England, E. (2003). Exposure to partner violence 

and child behavior problems: A prospective study controlling for child physical 

abuse and neglect, child cognitive ability, socioeconomic status and life stress. 

Development and Psychopathology, 15(1), 199-218. 
   APPENDIX 

A
 GRANTEE BENCHMARK
 IMPROVEMENT 

BACKGROUND 

Following the submission of performance data by Tribal Home Visiting grantees, 

ACF assessed whether each grantee demonstrated improvement in each of the 

benchmark areas outlined in the legislation and determined next steps if grantees 

did not demonstrate improvement. 

Legislative Requirements 

The legislation that created the Maternal, Infant, and Early Childhood Home 

Visiting program requires grantees to address six outcome domains: (1) improved 

maternal and newborn health; (2) prevention of child injuries, child abuse, neglect, 

or maltreatment and reduction of emergency department visits; (3) improvement 

in school readiness and achievement; (4) reduction in crime or domestic violence; 

(5) improvements in family economic self-sufficiency; and (6) improvements in the 

coordination and referrals for other community resources and supports. 

The legislation required state grantees to establish “quantifiable, measureable 

three and five-year benchmarks for demonstrating that the program results in 

improvements for the eligible families participating in the program” in these 

six domains (called “benchmark areas”). Per the statute, if grantees do not 

demonstrate improvement in at least four of the six benchmark areas after three 

years of implementation, they must develop a corrective action plan to improve 

their performance. State grantees who still fail to demonstrate improvement 

after completing their corrective action plans risk losing funding. 

According to the legislation, Tribal Home Visiting Program grants are to be 

consistent with the grants to states “to the extent practicable.” The statute requires 

that tribal grantees establish three and five-year benchmarks for demonstrating 

111 
 

112 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

improvement. On the other hand, the legislation does not explicitly require that 

tribal grantees must improve in four of the six benchmarks areas or that they 

develop a corrective action plan if they do not demonstrate improvement. 

Interpretation of Requirements 

As HRSA and ACF interpreted the legislation, tribal grantees are required to develop 

program performance measures related to each of the benchmark areas and to 

demonstrate quantifiable improvement using these performance measures. To 

develop performance measure requirements, the two federal agencies convened 

committees of experts to recommend aspects of each benchmark area that would 

be most important to measure. For example, in the area of improved maternal 

and child health, the experts recommended that grantees measure program 

performance in regard to promoting prenatal care, breastfeeding, well-child visits, 

and so on. For each of the benchmark areas, the experts identified two to nine 

different aspects (called “constructs”) that they considered to be essential. In total, 

the experts identified at least 35 separate constructs across all six benchmark areas. 

Based on these recommendations, ACF and HRSA required grantees to develop 

separate performance measures for each of the constructs and to collect the 

data necessary to track and assess their progress for each performance measure. 

For the Tribal Home Visiting Program, each grantee was required to develop and 

report on 36 separate performance measures—one for each of the constructs.25 

 For one of the six benchmark domains, grantees had the choice to measure either crime (two constructs) or domestic 

violence (three constructs). All Tribal Home Visiting grantees selected domestic violence; therefore, they must measure 

three different constructs in this benchmark area and a total of 36 constructs across all six benchmark areas. 

Because both state and tribal grantees were expected to implement a variety of 

home visiting models and to do so within diverse systems and contexts, ACF and 

HRSA determined that grantees should have maximum flexibility in developing 

performance measures. While this flexibility reduced the ability of ACF and HRSA 

to track grantee progress on a uniform set of performance measures, the benefits 

of this approach won out (particularly as they related to model developers’ 

existing data collection requirements). 

ACF gave Tribal Home Visiting Program grantees the following broad guidance in 

2011 about how improvement would be assessed after three years of program 

implementation: 

• Demonstrating improvement for a given construct (performance measure): 

For each performance measure, grantees are required to report two data 

values, a baseline value and a comparison value. In order to demonstrate 

26
GRANTEE BENCHMARK IMPROVEMENT 113 

improvement for the given performance measure, the grantee is simply 

required to demonstrate quantifiable improvement. 

•	 Demonstrating improvement for a given benchmark area: Grantees are 

required to demonstrate improvement in at least half of the constructs in a 

given benchmark area to demonstrate improvement for the benchmark area 

as a whole. 

•	 Demonstrating improvement overall: To align with the legislative 

requirement for state grantees, ACF determined that tribal grantees must 

demonstrate improvement in at least four of the six benchmark areas to be 

assessed as has having demonstrated overall improvement. 

ACF gave Cohort 1 Tribal Home Visiting Program grantees guidance in summer 

2014 that they must report benchmark data to ACF using the following crosssections that correspond to the federal reporting periods: 

•	 Baseline period: Benchmark data collected between the date the first 

participant was enrolled (this will be unique to each grantee site) and 

September 29, 2013 

•	 Comparison period: Benchmark data collected between September 30, 2013, 

and September 29, 2014 (the dates of the most recent reporting period) 

Tribal Home Visiting Benchmark Data Reporting 

ACF, in consultation with Tribal Home Visiting Program grantees and HRSA, 

developed a benchmarks reporting form for the grantees (Home Visiting Form 3, 

or HV Form 3) that was approved by the Office of Management and Budget in July 

2014. The HV Form 3 for tribal grantees is similar to a form (HV Form 2) used by 

state grantees, but with slight modifications to allow for tribal grantees to report 

benchmark data with an added level of specificity. 

ACF and HRSA directed the developers of the HRSA Discretionary Grants 

Information System (DGIS) to create a separate HV Form 3 module in the DGIS for 

Tribal Home Visiting Program grantees to submit their benchmark data. During 

the development phase, ACF had the option to adopt a feature in the system that 

would automatically calculate whether a grantee had improved on a particular 

construct. ACF decided not to include the automatic calculation feature, 

anticipating that in some cases it might be challenging to assess improvement. 

Therefore, within the DGIS for HV Form 3, an “Improvement” field contains 

a drop-down box with a “Yes” or “No” option. Because the system does not 

automatically determine improvement, the grantee selects “Yes” or “No” based 
 

114 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

on its assessment. Grantees must then provide a thorough explanation in the 

“Considerations for Improvement” field in DGIS to help ACF understand the 

degree of improvement or lack of improvement shown for each construct. 

Examples of the types of additional information provided by grantees in the 

“Considerations for Improvement” field may include the following: 

•	 A discussion of factors that contributed to the program’s success in 

demonstrating improvement 

•	 A clear explanation of why the data do not show quantifiable measureable 

improvement 

•	 An overview of data collection challenges or successes relevant to the construct 

•	 An explanation of limitations of the data that influence improvement between 

baseline and comparison (for example, a small sample size, lack of families 

who reach a particular assessment time point, “ceiling effects” due to high 

performance at baseline) 

•	 A description of programmatic challenges related to the construct, such 

as inadequate home visitor training, staff turnover, or poor community 

acceptance of a measure 

•	 Contextual information about the community or issues affecting data 

collection or service provision, such as poor family retention due to summer 

subsistence activities 

DISCUSSION 

Decision Rules for Assessing Improvement 

With this input from each grantee, ACF must make an official determination 

of improvement for each construct. When determining improvement from 

the federal perspective, ACF considered the data submitted along with the 

information provided in the “Considerations” field. 

The following decision rules guided ACF in determining if a grantee demonstrated 

improvement for each construct and benchmark area. These rules generally align 

with HRSA’s approach for assessing improvement for state grantees. 

1.	 Grantees were assessed as having improved on a particular construct if their 

data values moved in a positive direction (or in a negative direction if that is the 

desired improvement). The overall level of performance and the magnitude of 

the improvement were not taken into account when assessing improvement. 

For example, a grantee that moved from a two percent screening rate to a three 

percent screening rate was assessed as improved, even though its overall level 

of performance was low, and the increase was minimal. 
GRANTEE BENCHMARK IMPROVEMENT 115 

2.	 There are three exceptions to Rule #1: 

a. Grantees that did not have any data at baseline but performed at a very 

high level (90 percent or above/10 percent or below) at comparison were 

assessed as having improved. For example, if a grantee was unable to 

collect any baseline data related to screening of families for domestic 

violence but was able to collect data during the comparison period 

showing that 95 percent of families were screened for domestic violence, 

ACF gave the grantee credit for improvement. 

b.	 Grantees that had baseline data suggesting very high performance 

(90 percent or above/10 percent or below) and comparison data, while lower, 

also suggesting very high performance (90 percent or above/10 percent or 

below) were assessed as having improved. For example, if a grantee’s baseline 

data indicated 100 percent screening for maternal depression and comparison 

data dropped to 95 percent, ACF gave the grantee credit for improvement. 

c.	 If the benchmark measure involved action to be taken by a grantee or a 

change in participant status based upon some criteria set by the grantee 

(screens positive for domestic violence, decrease in percentage of children 

screening positive for delays), but no enrollees met that criteria at either 

time point, the designation was improvement for that benchmark. For 

example, grantees that screened participants for domestic violence 

(Construct 4.1) but did not have any “positive” screens automatically 

received “Yes” for Constructs 4.2 and 4.3 (“of families identified, number 

of referrals made to relevant services” and “of families identified, number 

of families for which a safety plan was completed”). 

3.	 All performance measures in a benchmark area counted toward the overall 

assessment of improvement in that area, whether or not a grantee had a strong 

rationale for why the data did not demonstrate improvement. In some cases, 

a grantee was able to provide a compelling reason for why it was not able to 

demonstrate improvement for a given construct, but ACF did not disregard the 

construct in determining this grantee’s improvement in a benchmark area. 

Limitations 

Though these rules are fair and defensible, the following issues are worth noting: 

•	 The data are imprecise. Due to the nature of this kind of performance 

data, the precision of the data is not high. For example, a grantee may have 

no data at baseline and 80 percent screening at follow-up. Technically, 

the number increased, but values at comparison were not high enough to 

merit a determination of improvement. ACF may be criticized by grantees 

with relatively high rates of performance at baseline that do not reach the 

proposed cutoff of 90 percent. In addition, ACF’s determinations may lead 
116 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

some stakeholders to draw the conclusion that the performance data values 

have more precision than they actually possess. 

•	 With the exception of rules 2a and 2b, ACF did not take a grantee’s overall 

level of performance on a construct into consideration when assessing 

improvement. Under the proposed decision rules, a grantee that moved from a 

25 percent to 35 percent screening rate will receive a “Yes” for improvement, but 

a grantee that moved from a 95 percent to 85 percent screening rate will receive 

a “No” for improvement. In other words, some grantees that demonstrate high 

overall levels of performance on a construct will be penalized and receive a 

“No” for improvement, whereas grantees that demonstrate low overall levels of 

performance, but show improvement, will receive a “Yes” for improvement 

•	 ACF did not take the number of participants served by a grantee into account 

when assessing improvement. For example, imagine that Grantee A served 

10 people in its baseline period and screened all 10 people; in its comparison 

period, it served 30 people and screened 25 people. Its performance data 

will show a decline from 100 percent to 83 percent, and it will be assessed as 

failing to demonstrate improvement. Alternatively, consider Grantee B, which 

served three people in its baseline period and screened only one person; in its 

comparison period it served six people, and it screened only three people. Its 

performance data will show an increase from 33 percent to 50 percent, and 

it will be assessed as demonstrating improvement. These scenarios raise a 

question of whether a grantee that serves more participants or substantially 

increases its number of participants should be held to the same standard as a 

grantee that serves a very low number of people. 

•	 ACF did not make accommodations for cases in which the grantee had 

very little control over the outcome of a performance measure. Some 

situations may occur in which the grantee has little control over the outcome 

of a performance measure and may feel that it should not be penalized for a 

decrease in performance. However, under the decision rules used, ACF did 

not make accommodations for such cases. 

•	 There were inconsistences in how grantees structured their performance 

measures. The grantees structured their performance measures differently, 

and these differences could have real implications for whether or not grantees 

are assessed as having improved. 

The decision rules were based on a clear and straightforward interpretation of 

the legislative language. The legislation requires that grantees demonstrate 

“measureable, quantifiable improvement.” These rules required grantees to do 

just that, while still appreciating the unique context of tribal grantees’ programs 

and applying the legislative language that tribal grants are to be consistent with 

state grants “to the extent practicable.” 
   APPENDIX
 

B
 IDENTIFYING CONSTRUCTS
 FOR DATA AGGREGATION 

VARIABILITY IN PERFORMANCE MEASURES 

As discussed in the report, grantees developed their own performance 

measurement plans detailing how they would measure, collect, and analyze 

data on the individual constructs within each of the six benchmark areas. While 

this flexibility permitted grantees to develop performance measures that were 

meaningful to their unique contexts and programs, it also resulted in widespread 

variability in performance measures across grantees. This variability stems from 

the following differences: 

• The specific definition of each performance measure 

• The type of measure used (outcome or process) 

• The target population identified for inclusion in measurement 

• The measurement time period 

• The value type (rate, percentage, mean, count) 

• The unit of analysis (incidents, participants) 

• If applicable, specific definitions of the numerator and denominator 

• The type of comparison (cohort, individual, cross-sectional) 

METHOD OF DATA AGGREGATION 

To provide additional insight on grantee program performance outside of 

determinations of improvement, data for select constructs were aggregated 

across grantees. Specifically, grantee-reported benchmark data in FY 2012 

and FY 2014, representing program performance between 2012 and 2014, 

117 
 

118 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

were aggregated. The method of data aggregation involved summing values 

across select grantees and reporting years to provide an estimate of overall 

performance on select constructs. For example, for the construct on maternal 

depression screening, many grantees reported the percentage of eligible 

women screened by an established time point (for example, six months after 

enrollment, six months after delivery). To aggregate data for this specific 

construct, the FY 2012 numerators were totaled across grantees (for those 

with similarly defined performance measures) and the FY 2014 numerators 

across grantees (again, for those with similarly defined performance measures) 

to provide an aggregate numerator. The same process was completed with 

the FY 2012 and FY 2014 denominators to provide an aggregate denominator. 

The aggregate numerator was then divided by the aggregate denominator 

to provide an aggregate percentage of the number of women screened for 

maternal depression. 

IDENTIFYING CONSTRUCTS WITH SIMILAR 

PERFORMANCE MEASURES 

To allow for meaningful aggregation and interpretation of data across 

grantees, measures of a construct must demonstrate sufficient alignment 

across the bulleted items outlined above. The process of nominating and 

selecting constructs for data aggregation involved a careful review of the 13 

Cohort 1 grantees’ performance measures, and the bulleted items outlined 

above, for all of the benchmark constructs. Constructs were considered 

for data aggregation if there was sufficient alignment across performance 

measures for at least five grantees. Alignment was considered sufficient if 

there were slight variations in the target populations and measurement time 

periods (for example, women four months postpartum versus women six 

months postpartum). 

IDENTIFIED CONSTRUCTS AND NUMBER 

OF GRANTEES REPRESENTED 

This table summarizes the final selection of constructs for data aggregation, the 

performance measure for the construct, and the number of grantees represented 

in aggregated data. 
IDENTIFYING CONSTRUCTS FOR DATA AGGREGATION 119 

Constructs Identified for Data Aggregation 

Construct Performance Measure 

Number of Grantees 

Included in 

Aggregated Data 

Prenatal Care Percentage of eligible participants 

initiating early prenatal care 

6 

Screening for Maternal 

Depressive Symptoms 

Percentage of eligible participants 

screened for maternal depression 

12 

Regular Visits to a Primary 

Healthcare Provider or 

Medical Home 

Percentage of eligible participants 

with visit to a primary healthcare 

provider or medical home 

8 

Information Provided on 

Prevention of Child Injuries 

Percentage of eligible participants 

who received information or 

training on prevention of child 

injuries 

13 

Incidence of Child Injuries 

Requiring Medical Treatment 

Rate of child injuries requiring 

medical treatment 

8 

First-Time Victims of 

Maltreatment 

Rate of first-time victims of 

maltreatment 

12 

Child Screening Rates in 

Developmental Domains 

Percentage of eligible children 

screened in developmental 

domains 

7 (child physical health 

and development), 

9 (remaining domains) 

Screening for Domestic 

Violence 

Percentage of eligible participants 

screened for domestic violence 

10 

Household Income and 

Benefits 

Percentage of eligible participants 

with increased household income 

or benefits 

5 

Families Identified for 

Necessary Services 

Percentage of eligible families 

screened for necessary services 

9 

Families Referred for 

Necessary Services 

Percentage of families identified 

for necessary services that 

received a referral 

11 

Completed Referrals Percentage of families receiving a 

referral that completed referral 

10 
This page is intentionally blank. 
 

 

   APPENDIX 

C
 LIMITATIONS OF
 BENCHMARK DATA 

The program performance data presented in this report represent the grantees’ 

extensive efforts in recruitment, retention, service provision, and data 

collection. However, as with all data, interpretation must be tempered with 

careful attention to their limitations. Some of the limitations of Tribal Home 

Visiting Program performance data include inconsistent and incomplete data, 

challenges related to culturally relevant measurement, small sample sizes, 

lack of comparison data, and insufficient time to demonstrate improvement. 

Performance measurement data can be a useful tool in understanding the 

growth and development of programs, but this information should not be 

confused with data that document program effect or impact. Documenting 

program impact requires a rigorous evaluation design and data from an 

equivalent comparison group. 

A RANGE OF LOCAL CHALLENGES THAT 

LED TO SOMETIMES INCONSISTENT 

AND INCOMPLETE DATA 

Data collection requirements presented new challenges for home visiting program 

staff. In some cases, grantees experienced setbacks in their data collection 

as they struggled to consistently collect necessary data while simultaneously 

delivering high quality services to families in the community. As a result, the data 

representing families served and services provided were likely underreported. 

Grantees are developing and implementing new strategies that promise to 

improve the consistency and completeness in data collection in the future. These 

strategies include integrating data collection discussions into regular home 

121 
122 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

visitor supervision, developing a custom data dashboard to facilitate real-time 

data checks, and incorporating a systematic review of data collection processes 

informed by home visitor experience. Additionally, grantees and TA providers 

have collaborated over the past year in the development of tools and strategies 

to improve data collection, which is intended to mitigate against this limitation in 

the future. 

SERVICE PROVISION TO SMALL COMMUNITIES 

LED TO SMALL SAMPLE SIZES 

Many of the tribal grantees are serving small communities. In some communities, 

the total number of families served is less than 50 families. This makes accurately 

measuring change difficult as just one family’s data could substantially skew the 

performance data for the entire program. Grantees continue to strategize around 

measuring change in small communities. Some grantees look to collaboration 

around data collection across sites, and perhaps by model, as a potential 

approach to explore. 

REQUIRED PERFORMANCE CONSTRUCTS 

DID NOT ACCOUNT FOR VARIATION 

IN MODEL OR PROGRAM FOCUS 

The 36 required performance constructs provided a helpful but limited view 

of program success. Because grantees had flexibility to utilize different home 

visiting models, the target population, program goals, and curricula varied across 

the grantees. In some instances, models did not focus on particular required 

performance areas. For example, a grantee may have delivered services with 

fidelity but failed to demonstrate improvement in prenatal health because their 

model targeted children after birth. 

LACK OF ASSESSMENT TOOLS VALIDATED 

WITH TRIBAL COMMUNITIES 

Tribal grantees frequently needed to assess outcomes for which there were no 

instruments validated for use in tribal settings or with AIAN individuals. While 

grantees were thoughtful in determining which tool would be most useful 

given these limitations, there may be instances in which assessments of certain 

outcomes may be inaccurate. For instance, grantees expressed that existing 

measures of parent-child interaction and parenting often feel invalid in a tribal 
 

LIMITATIONS OF BENCHMARK DATA 123 

setting. In AIAN communities, who provides care (parents, extended family 

members, other community members), how they interact with their children 

(non-verbal communication, through experiential learning, etc.), and what the 

home setting may look like may be different than in other contexts but may be 

appropriate caregiving. 

BENCHMARK DATA CAN DEMONSTRATE PROGRAM 

IMPROVEMENT NOT IMPACT 

The purpose of the benchmark requirement was not to measure impact or 

effectiveness but rather program improvement, and therefore a comparative 

design was not used. The goal of this type of performance measurement effort 

is to monitor program implementation and determine if grantees were making 

desired progress across a variety of indicators. Knowing whether a program 

“works,” requires a different approach to program design and data collection. In 

order to assess impact or effect, outcome data must be collected on families and 

children that did not participate in the program. Therefore, the data included in 

this report should not be used to determine program efficacy. 

SHORT TIMEFRAME FOR DEMONSTRATING 

IMPROVEMENT 

For many grantees, this program was the first in their communities to require 

extensive data collection. For these programs, successfully meeting the 

requirements first necessitated an extensive period to plan and build the 

infrastructure necessary for data collection. While it was time well spent, for 

some grantees, the time expended building the infrastructure delayed data 

collection. Implementation planning, infrastructure building, and training 

of staff sometimes meant that grantees began services later than expected. 

As a result, the window of time programs had to demonstrate program 

improvement was often shorter than anticipated. It is possible that some 

grantee programs will show greater progress and improved services with the 

expected growth in program implementation experience and with more time 

to refine services. 

When developing performance measures, grantees were acutely aware of 

and sometimes motivated by the need to demonstrate improvement within 

a short timeframe. This restricted the types of performance measures that 

were selected. For example, more process measures were selected, measures 

that don’t capture incremental change were not always considered, and target 
124 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

populations were narrowed to those who were likely to improve (e.g., families 

without insurance at intake, smokers at intake, families who score low on a 

particular measure at intake) which limited the number that could be reported 

and in many cases made the data challenging to interpret. There may be many 

indicators that are closely tied to home visiting processes and outcomes, feasible 

to measure, and appropriate for tribal communities, but they may not be 

sensitive to change within a short period of time. 
   APPENDIX 

D DATA TABLES 

DGIS DEMOGRAPHIC AND SERVICE UTILIZATION DATA
 

Participant Utilization of Program Services 

Number of Newly Enrolled Participants 2012-2014, Cohort 1 

FY2012 FY2013 FY2014 

TOTAL 

All Years 

Participant 

Type 

Total 

N= 9** 

M 

(SD)* 

Min. 

Max.* 

Total 

N= 13 

M 

(SD) 

Min. 

Max. 

Total 

N= 13 

M 

(SD) 

Min. 

Max. 

Total 

N= 35 

M 

(SD) 

Min. 

Max. 

Families 169 18.78 

(12.77) 

4/40 464 35.69 

(27.91) 

6/96 434 33.38 

(29.19) 

4/90 1067 30.49 4/96 

Participants 179 19.89 

(12.44) 

4/40 569 43.77 

(37.42) 

9/130 509 39.15 

(33.26) 

4/103 1257 35.91 4/130 

Children 163 18.11 

(12.99) 

5/44 452 34.77 

(27.07) 

6/105 489 37.62 

(31.2) 

4/107 1104 31.54 4/107 

*Note: Where Min.Max. or SD presented, refers to variability across grantees.**N’s reported reflect the number of grantees reporting 

Participant Utilization of Program Services 

Number of Newly Enrolled Participants 2012-2014, Cohort 2 

FY2013 FY2014 

TOTAL 

All Years 

Participant 

Type 

Total 

N = 2 

M 

(SD) 

Min. 

Max. 

Total 

N = 6 

M 

(SD) 

Min. 

Max. 

Total 

N = 8 

M 

(SD) 

Min. 

Max. 

Families 20 10 

(4.24) 

7/13 204 34 

(31.23) 

9/89 224 28.0 7/89 

Participants 20 10 

(4.24) 

7/13 207 34.5 

(32.29) 

9/92 227 23.38 7/92 

Children 13 6.5 

(6.36) 

2/11 202 33.67 

(44.83) 

8/124 215 26.88 2/124 

125 
126 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Participant Utilization of Program Services 

Number of Newly Enrolled Participants 2012-2014, Cohort 3 

FY2014 

Participant Type 

Total Newly Enrolled 

N = 6 

M 

(SD) 

Min. 

Max. 

Families 232 38.67 

(68.27) 

2/176 

Participants 216 36.0 

(61.84) 

2/160 

Children 178 29.67 

(51.59) 

0/132 

Participant Utilization of Program Services 

Number of Participants Served 2012-2014, Cohort 1 

FY2012 FY2013 FY2014 

Participant 

Type 

Total 

Served 

N = 9 

M 

(SD)* 

Min. 

Max. 

Total 

Served 

N = 13 

M 

(SD) 

Min. 

Max. 

Total 

Served 

N = 13 

M 

(SD) 

Min. 

Max. 

Families 169 18.78 

(12.77) 

4/40 593 45.62 

(39.32) 

6/132 887 68.23 

(60.69) 

10/226 

Participants 179 19.89 

(12.44) 

4/40 702 54 

(45.97) 

9/137 1000 76.92 

(62.18) 

12/226 

Children 163 18.11 

(12.99) 

5/44 571 43.92 

(36.88) 

6/137 957 73.62 

(52.67) 

11/195 

Participant Utilization of Program Services 

Number of Participants Served 2012-2014, Cohort 2 

FY2013 FY2014 

Participant Type 

Total 

Served 

N = 2 

M 

(SD) 

Min. 

Max. 

Total 

Served 

N = 6 

M 

(SD) 

Min. 

Max. 

Families 20 10 

(4.24) 

7/13 222 37 

(31.5) 

9/89 

Participants 20 10 

(4.24) 

7/13 225 37.5 

(32.5) 

9/92 

Children 13 6.5 

(6.36) 

2/11 221 36.83 

(43.56) 

8/124 
DATA TABLES 127
 

Participant Utilization of Program Services 

Number of Participants Served 2012-2014, Cohort 3 

FY2014 

Participant Type 

Total Served 

N = 6 

M 

(SD) 

Min. 

Max. 

Families 232 38.67 

(68.27) 

2/176 

Participants 216 36 

(61.84) 

2/160 

Children 178 29.67 

(51.59) 

0/132 

Participant Utilization of Program Services 

Percentage of Participants Pregnant at Enrollment, Male Caregivers, Female Caregivers, Cohort 1 

FY2012 FY2013 FY2014 

Participant 

Type 

Total 

% 

M 

(SD) 

Min. 

Max. 

Total 

% 

M 

(SD) 

Min. 

Max. 

Total 

% 

M 

(SD) 

Min. 

Max. 

Pregnant at 

Enrollment 

31.84 

N = 57 

26.73 

(23.42) 

0/77.5 37.68 

N = 107 

31.36 

(19.14) 

0/64 27.50 

N = 275 

28.33 

(15.39) 

7.69/55.88 

Male 

Caregivers 

8.38 

N = 15 

11.75 

(14.83) 

0/35.29 9.18 

N = 57 

11.21 

(13.83) 

0/38.24 13.30 

N = 133 

13.13 

(13.83) 

0/40.66 

Female 

Caregivers 

59.78 

N = 107 

61.52 

(21.75) 

22.5/100 53.14 

N = 330 

57.43 

(17.71) 

36/100 59.2 

N = 592 

58.54 

(12.62) 

41.67/84 

Participant Utilization of Program Services 

Percentage of Participants Pregnant at Enrollment, Male Caregivers, Female Caregivers, Cohort 2 

FY2013 FY2014 

Participant Type 

Total 

% 

M 

(SD) 

Min. 

Max. 

Total 

% 

M 

(SD) 

Min. 

Max. 

Pregnant at Enrollment 55 

N = 11 

65.38 

(48.95) 

30.77/100 42.22 

N = 95 

33.23 

(34.51) 

0/100 

Male Caregivers 0 

N = 0 

n/a n/a 5.33 

N = 12 

3.34 

(4.04) 

0/9.78 

Female Caregivers 45 

N = 9 

34.62 

(48.95) 

0/69.23 52.44 

N = 118 

63.43 

(33.51) 

0/100 
128 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Participant Utilization of Program Services 

Percentage of Participants Pregnant at Enrollment, 

Male Caregivers, Female Caregivers, Cohort 3 

FY2014 

Participant Type 

Total 

% 

M 

(SD) 

Min. 

Max. 

Pregnant at Enrollment 34.72 

N = 75 

60.63 

(41.11) 

0/100 

Male Caregivers .93 

N = 2 

2.19 

(5.06) 

0/12.5 

Female Caregivers 64.35 

N = 139 

37.18 

(37.47) 

0/87.5 

Participant Utilization of Program Services 

Number of Home Visits Provided, Cohort 1 

FY2012 FY2013 FY2014 

Total 

All Years 

Total M Min. Total M Min. Total M Min. Total M Min. 

N= 9 (SD) Max. N= 13 (SD) Max. N= 13 (SD) Max. N= 35 (SD) Max. 

Number 759 84.33 8/257 5831 448.54 29/1226 9819 755.31 33/2727 16409 468.83 8/2727 

of Home (80.18) (384.32) (699.04) 

Visits 

Provided 

Participant Utilization of Program Services 

Number of Home Visits Provided, Cohort 2 

FY2013 FY2014 

Total 

All Years 

Total M Min. Total M Min. Total M Min. 

N= 2 (SD) Max. N= 6 (SD) Max. N= 8 (SD) Max. 

Number of 120 60 25/95 1710 285 44/526 1830 228.75 25/526 

Home Visits (49.5) (227.58) 

Provided 
 

DATA TABLES 129
 

Participant Utilization of Program Services 

Number of Home Visits Provided, Cohort 3 

FY2014 

Total 

N = 6 

M 

(SD) 

Min. 

Max. 

Number of Home Visits Provided 1418 236.33 

(335.23) 

2/799 

Service Utilization Across Models 

Family Retention, Cohort 1 

FY2012 FY2013 FY2014 

Total 

N = 9 

M 

(SD) 

Min. 

Max. 

Total 

N = 13 

M 

(SD) 

Min. 

Max. 

Total 

N = 13 

M 

(SD) 

Min. 

Max. 

Currently receiving 

services 

158 17.56 

(13.4) 

3/40 478 36.77 

(31.86) 

6/101 633 48.69 

(40.78) 

8/155 

Completed program 0 0 0/0 5 .38 

(.77) 

0/2 22 1.69 

(3.50) 

0/13 

Stopped services 

before completion 

3 .33 

.5 

0/1 86 6.62 

(8.97) 

0/31 204 15.69 

(18.76) 

1/69 

Other 8 .89 

(2.32) 

0/7 16 1.23 

(3.14) 

0/11 28 2.15 

(6.34) 

0/23 

Attrition Rate 2% 14.5% 23% 

Service Utilization Across Models 

Family Retention, Cohort 2 

FY2013 FY2014 

Total

 N = 2 

M 

(SD) 

Min. 

Max. 

Total 

N = 6 

M 

(SD) 

Min. 

Max. 

Currently receiving services 20 10 

(4.24) 

7/13 185 30.83 

(27.06) 

8/77 

Completed program 0 0 0 0 0 0 

Stopped services before completion 0 0 0 36 6 

(6.6) 

0/15 

Other 0 0 0 1 .17 

(.41) 

0/1 

Attrition Rate 0% 16.2% 
130 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Service Utilization Across Models 

Family Retention, Cohort 3 

FY2014 

Total 

N = 6 

M 

(SD) 

Min. 

Max. 

Currently receiving services 204 34 

(61.02) 

2/156 

Completed program 0 0 0 

Stopped services before completion 7 1.17 

(2.04) 

0/5 

Other 21 3.5 

(8.09) 

0/20 

Participant Characteristics 

Age Distribution of Adult Program Participants 

15-17 18-19 20-21 22-24 25-29 30-34 35-44 45-54 55-64 65+ Unknown 

Pregnant %* %* %* %* %* %* %* %* %* %* %* 

Women (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. 

Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) 

6.3 10.6 17.1 21.3 27.3 12.3 4.9 .2 0 0 2.9 

N = 27 N = 46 N = 74 N = 92 N = 118 N = 53 N = 21 N = 1 N= 0 N = 0 N = 13 

(0/20) (0/50) (0/60) (0/75) (0/85.71) (0/50) (0/16.67) (0/10) (0/40) 

Female %* %* %* %* %* %* %* %* %* %* %* 

Caregivers (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. 

Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) 

1.8 5.6 12.0 19.6 30.3 15.3 11.9 2.0 1.1 .4 6.7 

N = 14 N = 44 N = 95 N =155 N = 240 N =121 N = 94 N = 16 N =9 N = 3 N = 57 

(0/6.25) (0/20) (0/60) (0/43.75) (0/44.44) (0/100) (0/33.33) (0/10) (0/20) (0/2.5) (0/50) 

Male %* %* %* %* %* %* %* %* %* %* %* 

Caregivers (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. (Min. 

Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) Max.) 

.8 4.2 7.5 16.7 25.8 20.0 13.3 7.5 3.3 .8 18.4 

N = 1 N = 5 N = 9 N = 20 N = 31 N = 24 N = 16 N = 9 N =4 N = 1 N = 27 

(0/14.29) (0/25) (0/33.33) (0/100) (0/100) (0/50) (0/25) (0/25) (0/25) (0/16.67) (0/100) 

*Note: Min.Max.s are Min.Max. in % to give picture of proportion of participants in certain categories across grantees. 
DATA TABLES 131
 

Participant Characteristics 

Age Distribution of Child Participants 

Under 1 

N =437 

1-2 Years 

N =595 

3-5 Years 

N =279 

Unknown 

N =45 

Index Children % (Min.Max.) 

33.33 

(0/100) 

% (Min.Max.) 

45.39 

(0/75) 

% (Min.Max.) 

21.28 

(0/50) 

% (Min.Max.) 

3.32 

(0/100) 

Participant Characteristics 

Race of Program Participants 

American Native More 

Indian or Black or Hawaiian than one 

Alaska African or Pacific Category 

Native Asian American Islander White Selected Unrecorded 

Adult % (Min. % (Min. % (Min. % (Min. % (Min. % (Min. % (Min. 

Program Max.) Max.) Max.) Max.) Max.) Max.) Max.) 

Participants 78.3 

N = 1021 

(49.24/100) 

.3 

N = 4 

(0/6.25) 

.7 

N = 9 

(0/3.8) 

.2 

N = 3 

(0/4) 

10 

N = 131 

(0/26.47) 

10.4 

N = 136 

(0/46.7) 

9.5 

N = 137 

(0/72.83) 

Index 

Children 

% (Min. 

Max.) 

84.6 

N = 1009 

(44.64/100) 

% (Min. 

Max.) 

.1 

N = 1 

(0/3.57) 

% (Min. 

Max.) 

.4 

N = 5 

(0/3.88) 

% (Min. 

Max.) 

.2 

N = 2 

(0/.78) 

% (Min. 

Max.) 

4.2 

N = 50 

(0/12.82) 

% (Min. 

Max.) 

10.6 

N = 126 

(0/52.63) 

% (Min. 

Max.) 

12 

N = 163 

(0/83.06) 

Participant Characteristics 

Ethnicity of Program Participants 

Hispanic or Latino Non-Hispanic or Latino Unrecorded 

Adult Program 

Participants 

% (Min.Max.) 

7.1 

N = 91 

(0/100) 

% (Min.Max.) 

92.9 

N = 1190 

(0/100) 

% (Min.Max.) 

11.1 

N = 160 

(0/100) 

Index Children % (Min.Max.) 

7.1 

N = 91 

(0/100) 

% (Min.Max.) 

92.9 

N = 1190 

(0/100) 

% (Min.Max.) 

11.1 

N = 160 

(0/100) 
132 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Participant Characteristics 

Marital Status of Adult Program Participants 

Divorced Married Separated 

Single, Never 

Married Widowed 

Unknown/ 

did not 

report 

Adult Program 

Participants 

% (Min.Max.) 

2.99 

N = 36 

(0/22.22) 

% (Min.Max.) 

24.9 

N = 300 

(0/62.5) 

% (Min.Max.) 

2.24 

N = 27 

(0/5.88) 

% (Min.Max.) 

69.79 

N = 841 

(37.5/100) 

% (Min.Max.) 

.08 

N = 1 

(0/.62) 

% (Min.Max.) 

16.38 

N = 236 

(0/70) 

Participant Characteristics 

Educational Attainment of Adult Program Participants 

Enrolled 

in high 

school 

High school 

eligible, not 

enrolled 

Less than a 

high school 

diploma 

High 

school 

diploma GED 

Some 

college/ 

training 

Technical 

training 

certification 

of Associate’s 

Degree 

Bachelor’s 

Degree or 

Higher 

Unknown/ 

Did not 

report 

Adult 

Program 

Participants 

%* 

(Min. 

Max.) 

4.33 

N = 49 

(0/50) 

%* 

(Min. 

Max.) 

1.59 

N = 18 

(0/12.5) 

%* 

(Min. 

Max.) 

20.85 

N = 236 

(0/50) 

%* 

(Min. 

Max.) 

36.48 

N = 413 

(0/61.82) 

%* 

(Min. 

Max.) 

8.22 

N = 93 

(0/33.33) 

%* 

(Min. 

Max.) 

15.81 

N = 179 

(0/55.56) 

%* 

(Min. 

Max.) 

8.3 

N = 94 

(0/50) 

%* 

(Min. 

Max.) 

4.42 

N = 50 

(0/20) 

%* 

(Min. 

Max.) 

21.44 

N = 309 

(0/74.38) 

Participant Characteristics 

Insurance Status of Program Participants 

No insurance 

coverage Medicaid/SCHIP TRICARE 

Private or 

other health 

insurance 

coverage 

Unknown/ 

Did not report 

Adult Program 

Participants 

% (Min.Max.) 

18.2 

N = 222 

(0/87.5) 

% (Min.Max.) 

68.9 

N = 839 

(0/100) 

% (Min.Max.) 

0 

N = 0 

% (Min.Max.) 

12.9 

N = 157 

(0/80) 

% (Min.Max.) 

15.5 

N = 223 

(0/73.75) 

Index Children % (Min.Max.) 

10.5 

N = 130 

(0/100) 

% (Min.Max.) 

81.8 

N = 1014 

(0/100) 

% (Min.Max.) 

0 

N = 0 

% (Min.Max.) 

7.7 

N = 95 

(0/26.79) 

% (Min.Max.) 

8.6 

N = 117 

(0/42.27) 
DATA TABLES 133
 

Participant Characteristics 

Employment and Educational/Training Status of Adult Program Participants 

Employment Status Educational/Training Status 

Employed 

full time 

Employed 

part time 

Not 

employed Unknown 

Student/ 

trainee 

Not a 

student/ 

trainee Unknown 

Adult Program 

Participants 

% (Min.Max.) 

26.37 

N = 313 

(0/51.02) 

% (Min.Max.) 

14.32 

N = 170 

(0/29.41) 

% (Min.Max.) 

59.31 

N = 704 

(36.73/83.33) 

% (Min.Max.) 

17.63 

N = 254 

(0/79.38) 

% (Min.Max.) 

14.9 

N = 163 

(0/50) 

% (Min.Max.) 

85.1 

N = 930 

(50/100) 

% (Min.Max.) 

24.1 

N = 348 

(0/78.13) 

Participant Characteristics 

Household Income Status in Relation to Federal Poverty Guidelines 

50% and 

under 51-100% 101-133% 134-250% 251-300% >300% Unknown 

Households % (Min. 

Max.) 

42.9 

N = 410 

(0/100) 

% (Min. 

Max.) 

28.1 

N = 269 

(0/58.54) 

% (Min. 

Max.) 

12.2 

N = 117 

(0/28.57) 

% (Min. 

Max.) 

13.1 

N = 125 

(0/80) 

% (Min. 

Max.) 

1.9 

N = 18 

(0/20) 

% (Min. 

Max.) 

1.8 

N = 17 

(0/14.71) 

% (Min. 

Max.) 

27.7 

N = 366 

(0/100) 

Participant Characteristics 

Primary Language Exposure for Index Children 

English Spanish 

Tribal 

languages Other Unknown 

Index Children % (Min.Max.) 

98.2 

N = 1178 

(36.36/100) 

% (Min.Max.) 

.3 

N = 4 

(0/10.53) 

% (Min.Max.) 

1.4 

N = 17 

(0/63.64) 

% (Min.Max.) 

0 

N = 0 

% (Min.Max.) 

11.6 

N = 157 

(0/90.15) 
134 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Program Reach across Priority Populations 

New Enrollees in Priority Population Categories, Cohort 1 

Low 

income 

Pregnant 

women 

under 21 

History of 

child abuse 

or neglect 

History of 

substance 

abuse 

Users of 

tobacco 

products 

Have 

children with 

low student 

achievement 

Have 

children with 

developmental 

delay or 

disabilities 

Serving or 

formerly 

served 

in armed 

forces 

2012 New % % % % % % % % 

enrollees (Min.Max.) 

60.3 

N = 108 

(17.65/100) 

(Min.Max.) 

12.8 

N = 23 

(0/37.5) 

(Min.Max.) 

16.2 

N = 29 

(0/50) 

(Min.Max.) 

21.2 

N = 38 

(0/75) 

(Min.Max.) 

17.3 

N = 31 

(0/50) 

(Min.Max.) 

2.2 

N = 4 

(0/50) 

(Min.Max.) 

14.5 

N = 26 

(0/50) 

(Min.Max.) 

1.7 

N = 3 

(0/25) 

2013 New % % % % % % % % 

enrollees (Min.Max.) 

49.2 

N = 280 

(0/100) 

(Min.Max.) 

13.7 

N = 78 

(0/41.18) 

(Min.Max.) 

15.6 

N = 89 

(0/70.59) 

(Min.Max.) 

19.7 

N = 112 

(0/45.45) 

(Min.Max.) 

15.3 

N = 87 

(0/76.47) 

(Min.Max.) 

5.8 

N = 33 

(0/35.29) 

(Min.Max.) 

10.5 

N = 60 

(0/52.94) 

(Min.Max.) 

3.0 

N = 17 

0/8.82) 

2014 New % % % % % % % % 

enrollees (Min.Max.) 

61.3 

N = 312 

(28.57/100) 

(Min.Max.) 

9.2 

N = 47 

(0/75) 

 (Min.Max.) 

13.6 

N = 69 

(0/39.29) 

(Min.Max.) 

25 

N = 127 

(0/68.42) 

(Min.Max.) 

16.7 

N = 85 

(0/56.25) 

(Min.Max.) 

8.4 

N = 43 

(0/36.84) 

(Min.Max.) 

6.5 

N = 33 

(0/17.86) 

(Min.Max.) 

2.6 

N = 13 

(0/5.56) 

Program Reach across Priority Populations 

New Enrollees in Priority Population Categories, Cohort 2 

Low 

income 

Pregnant 

women 

under 21 

History of 

child abuse 

or neglect 

History of 

substance 

abuse 

Users of 

tobacco 

products 

Have 

children with 

low student 

achievement 

Have 

children with 

developmental 

delay or 

disabilities 

Serving or 

formerly 

served 

in armed 

forces 

2013 New % % % % % % % % 

enrollees (Min.Max.) 

100 

N = 20 

(100/100) 

(Min.Max.) 

25 

N = 5 

(0/71.43) 

(Min.Max.) 

35 

N = 7 

(14.29/46.15) 

(Min.Max.) 

25 

N = 5 

(23.08/28.57) 

(Min.Max.) 

30 

N = 6 

(14.29/38.46) 

(Min.Max.) 

10 

N = 2 

(0/15.38) 

(Min.Max.) 

10 

N = 2 

(0/15.38) 

(Min.Max.) 

0 

N = 0 

2014 New % % % % % % % % 

enrollees (Min.Max.) 

72.9 

N = 151 

(33.33/100) 

(Min.Max.) 

11.1 

N = 23 

(0/34.62) 

(Min.Max.) 

7.2 

N = 15 

(0/35) 

(Min.Max.) 

29.5 

N = 61 

(0/55.56) 

(Min.Max.) 

13.5 

N = 28 

(0/55.56) 

(Min.Max.) 

1.4 

N = 3 

(0/11.11) 

(Min.Max.) 

2.4 

N = 5 

(0/15) 

(Min.Max.) 

1.4 

N = 3 

(0/2.17) 
DATA TABLES 135 

DGIS PERFORMANCE MEASUREMENT DATA 

Program Performance Domain 1 

Percentage of Grantees Demonstrated Improvement in Benchmark Areas, 

Maternal and Newborn Health 

Construct 

Improvement 

Yes/ N (%) No/ N (%) 

Prenatal Care 10 (77) 3 (23) 

Alcohol, Tobacco, and Illicit Drugs 9 (69) 4 (31) 

Preconception Care 9 (69) 4 (31) 

Inter-Birth Interval 5 (39) 8 (62) 

Maternal Depressive Symptoms 10 (77) 3 (23) 

Breastfeeding 8 (62) 5 (39) 

Well-Child Visits 4 (31) 9 (69) 

Maternal and Child Health Insurance Status 6 (46) 7 (54) 

Regular Visits to a Primary Healthcare Provider or Medical Home 12 (92) 1 (8) 

Program Performance Domain 1 

Percentage of Grantees Demonstrated Grantee Defined Improvement 

Construct 

Grantee Defined Improvement 

% (Percentage range) 

(Number of grantees reporting; N) 

Early Initiation of Prenatal Care 89.5 (73.08-100) 

(6 grantees; N = 381) 

Screening for Maternal Depressive Symptoms 71 (29.73-100) 

(12 grantees; N = 469) 

Mothers and Children Obtained Maternal and Child Health Insurance 

by 12 months post enrollment 

85.92 (56.25-100) 

(6 grantees; N = 966) 

Regular Visits to a Primary Healthcare Provider or Medical Home for 

Mother and/or child 

40.48 (27.17-100) 

(8 grantees; N = 914) 
136 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Program Performance Domain 2 

Percentage of Grantees Demonstrated Improvement in Benchmark Area Child Injuries, 

Child Abuse, Neglect or Maltreatment 

Construct 

Improvement 

Yes No 

Visits for Children to Emergency Department 7 (54%) 6 (46%) 

Visits for Mothers to Emergency Department 5 (39%) 8 (62%) 

Information/Training on Prevention of Child Injuries 9 (69%) 4 (31%) 

Incidence of Child Injuries 10 (77%) 3 (23%) 

Reported Suspected Maltreatment 9 (69%) 4 (31%) 

Reported Substantiated Maltreatment 12 (92%) 1 (8%) 

First Time Victims of Maltreatment 12 (92%) 1 (8%) 

Program Performance Domain 2 

Percentage of Grantees Demonstrated Grantee Defined Improvement 

Construct 

Grantee Defined Improvement 

% (Percentage range) 

(Number of grantees reporting; N) 

Information/Training on Prevention of Child Injuries 50.05 (5.88-96.43) 

(13 grantees; N = 949) 

Incidence of Child Injuries 3.56 (0-50) 

(8 grantees; N = 702) 

First Time Victims of Maltreatment 9.93 (0-66.67) 

(12 grantees; N = 745) 

Program Performance Domain 3 

Percentage of Grantees Demonstrated Improvement in Benchmark Areas, 

School Readiness and Achievement 

Construct 

Improvement 

Yes No 

Parent Support for Child Learning and Development 7 (54%) 6 (46%) 

Parent Knowledge of Child Development 10 (77%) 3 (23%) 

Parenting Behaviors/Parent-Child Relationship 9 (69%) 4 (31%) 

Parent Emotional Well-Being/Parenting Stress 12 (92%) 1 (8%) 

Child Communication, Language, and Emergent Literacy 8 (61%) 5 (39%) 

Child Cognitive Skills 8 (62%) 5 (39%) 

Child Positive Approaches to Learning 7 (54%) 6 (46%) 

Child Social Behavior/Emotional Well-Being 6 (46%) 7 (54%) 

Child Physical Health and Development 7 (54%) 6 (46%) 
DATA TABLES 137
 

Program Performance Domain 3 

Percentage of Grantees Demonstrated Grantee Defined Improvement 

Construct 

Grantee Defined Improvement 

% (Percentage range) 

(Number of grantees reporting; N) 

Child Communication, Language, and Emergent Literacy 55.36 (27.97-96.55) 

(9 grantees; N = 681) 

Child Cognitive Skills 55.49 (27.97-96.55) 

(9 grantees; N = 692) 

Child Positive Approaches to Learning 49.13 (6.25-96.55) 

(9 grantees; N =743) 

Child Social Behavior/Emotional Well-Being 42.53 (16.8-91.49) 

(9 grantees; N =696) 

Child Physical Health and Development 68.06 (32.81-96.55) 

(7 grantees; N = 695) 

Program Performance Domain 4 

Percentage of Grantees Demonstrated Improvement in Benchmark Areas, 

Crime or Domestic Violence 

Construct 

Improvement 

Yes No 

Screening for Domestic Violence 7 (54%) 6 (46%) 

Referrals for Domestic Violence Services 9 (69%) 4 (31%) 

Domestic Violence – Safety Plan 9 (69%) 4 (31%) 

Arrests* NA NA 

Convictions* NA NA 

*No grantees selected arrests or convictions as a benchmark performance measure. 

Program Performance Domain 4 

Percentage of Grantees Demonstrated Grantee Defined Improvement 

Construct 

Grantee Defined Improvement 

% (Percentage range) 

(Number of grantees reporting; N) 

Screening for Domestic Violence 59.32 (30.23-100) 

(10 grantees; N =617) 
138 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Program Performance Domain 5 

Percentage of Grantees Demonstrated Improvement in Benchmark Areas, 

Family Economic Self-Sufficiency 

Construct 

Improvement 

Yes No 

Income and Benefits 9 (69%) 4 (31%) 

Employment of Education 8 (62%) 5(39%) 

Health Insurance Status 11 (85%) 2 (15%) 

Program Performance Domain 5 

Percentage of Grantees Demonstrated Grantee defined Improvement 

Construct 

Grantee Defined Improvement 

% (range) 

(# of grantees reporting; N) 

Income and Benefits 19.34 (0-79.19%) 

(5 grantees; N= 305) 

Program Performance Domain 6 

Percentage of Grantees Demonstrated Improvement in Benchmark Areas, 

Coordination and Referrals for Other Community Resources & Supports 

Construct 

Improvement 

Yes No 

Identification for Necessary Services 7 (54%) 6 (46%) 

Referrals for Necessary Services 10 (77%) 3 (23%) 

Receipt of Necessary Services 7 (54%) 6 (46%) 

Information Sharing 6 (46%) 7 (54%) 

Number of MOUs 12 (92%) 1 (8%) 
DATA TABLES 139
 

Program Performance Domain 6 

Percentage of Grantees Demonstrated Grantee defined Improvement 

Construct 

Grantee Defined Improvement 

% (Percentage range) 

(Number of grantees reporting; N) 

Identification for Necessary Services 73.65 (8-100) 

(9 grantees; N =892) 

Referrals for Necessary Services 75.5 (4-100) 

(11 grantees; N = 804) 

Receipt of Necessary Services 66.25 (46.15-100) 

(10 grantees; N = 806) 

Number of MOUs 395 (Count: 0-200) 

(11 grantees; N/A) 

Information Sharing 717 (Count: 13-200) 

(12 grantees; N/A) 

Program Performance Overall 

Percentage of Grantees Demonstrated Improvement Overall 

Improvement 

Yes= 10 (76.9%) 

N = 3 (23.1%)
	

Program Performance 

Percentage of Grantees Demonstrated Improvement by Benchmark Area 

Benchmark Area Improvement (%) 

Maternal and Newborn Health N = 8 (62) 

Child Injuries, Child Abuse, ED Visits N = 11 (85) 

School Readiness and Achievement N = 9 (69) 

Crime or Domestic Violence N = 10 (77) 

Family Economic Self-Sufficiency N = 10 (77) 

Coordination and Referrals for Other Community Resources & Supports N = 9 (69) 
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E 

APPENDIX SUMMARY OF TRIBAL
 MIECHV BENCHMARK
 PERFORMANCE 

MEASURES 

INTRODUCTION AND OVERVIEW 

The Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) 

Program, administered by the Administration for Children and Families (ACF) in 

collaboration with the Health Resources and Services Administration, aims to 

improve health and developmental outcomes for mothers and children through 

implementation of evidence-based home visiting models. Funding requirements 

stipulate that grantees demonstrate quantifiable and measurable improvements 

across the following federal benchmark domains: 

1.	 Maternal, newborn, and child health 

2.	 Child injuries; child abuse, neglect, or maltreatment; and emergency 

department visits 

3.	 School readiness and achievement 

4.	 Crime or domestic violence 

5.	 Family economic self-sufficiency 

6.	 Coordination and referrals for other community resources and supports 

To measure and demonstrate performance improvement across the benchmark 

domains, grantees were required to develop benchmark plans that describe the 

process to be used in identifying quantifiable, measurable performance measures. 

For over two years, Tribal Home Visiting26 grantees worked with the Administration 

for Children and Families and members of the Tribal Home Visiting Evaluation 

26 Throughout this document, “Home Visiting” refers specifically to the Maternal, Infant, and Early Childhood Home 

Visiting Program. 

141 
 

 

142 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Institute (TEI) to develop strong performance measurement plans. TEI provided 

intensive individualized technical assistance to ensure that grantees meet federal 

requirements and the requirements of the home visiting model developers, develop 

performance measures that are meaningful to programs and communities, and 

collect data that can be used internally to continuously improve the quality of their 

home visiting programs. 

This summary provides an overview of all 25 approved Tribal Home Visiting 

Program benchmark plans as of May 1, 2014. Information was gathered from each 

plan, including the stated performance measure, the type of measure (outcome or 

process), the data source (client, home visitor, or administrative records), the target 

population, the tool or measure selected by the grantee, and the measurement 

period. Information was also collected on the type of comparisons used to 

demonstrate improvement (individual, cohort, or cross-sectional comparison of 

data), the direction of improvement needed to determine success, the unit of 

analysis, and the type of scoring. This summary describes the grantees’ benchmark 

plans across and within constructs. It includes a description of themes within each 

benchmark domain and a discussion of alignment—or the degree of similarity—of 

grantee measurement choices within each construct. 

SUMMARY ACROSS MEASURES 

Home visiting grantees were given the flexibility to develop performance measures 

that were meaningful to their programs and appropriate for the community 

context. As a result, across grantees, different indicators were selected to represent 

each construct and were measured using a variety of tools across a range of time 

points. While this approach has strengths, allowing for varying dimensions of 

each construct to be captured, it complicates the ability to summarize grantee 

performance measures across programs, constructs, and benchmark domains. 

This section explores the alignment across grantee-developed performance 

measures. The degree of alignment is an important consideration because it 

impacts the ability to summarize and draw conclusions from grantee performance 

measurement results. The information is summarized below. 

Summary of Benchmark Domains 

Benchmark Domain 1: Maternal, Child, and Newborn Health 

• In seven of the nine maternal and newborn health constructs, the majority of 

grantees chose outcome measures to examine performance. 
SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 143 

•	 In a majority of cases, grantees are collecting maternal and newborn health 

data through self-report. For example, just one of 25 grantees collects 

administrative data to track prenatal care, and three grantees (12 percent) rely 

on administrative data to track well-child visits. 

•	 Grantees use a variety of screening instruments to examine substance use 

(Construct 1.2) and maternal depression (Construct 1.5). Grantees use seven 

different screeners for alcohol, tobacco, or other drugs and six maternal 

depression assessments. 

Benchmark Domain 2: Child Injuries; Child Abuse, Neglect, or 

Maltreatment; and Emergency Department Visits 

•	 With the exception of information/training on prevention of child injuries 

(Construct 2.3), the vast majority of grantees are using outcome measures to 

assess program performance related to prevention of childhood injuries and 

child maltreatment. 

•	 Grantees are using a combination of administrative data and participant 

self-report to track child maltreatment outcomes. Over half the grantees 

(56 percent, n=14) are tracking reports of suspected maltreatment with 

administrative data. Sixty percent (n=15) are tracking substantiated reports 

and first-time victims of maltreatment through administrative records. 

Benchmark Domain 3: School Readiness and Achievement 

•	 A majority of grantees are using outcome measures in three of the four 

constructs that examine parent knowledge and behavior (Constructs 3.1–3.4). 

Grantees are collecting these data through a variety of parenting measures, 

including six unique measures to track parent support of child learning and 

development (Construct 3.1) and eight different measures to assess parent 

knowledge of child development (Construct 3.2). 

•	 The majority of grantees are using process measures to assess program 

performance for all five constructs focused on child behavior and 

development (Constructs 3.5–3.9). 

•	 The Ages and Stages Questionnaire-3 (ASQ-3) and Ages and Stages 

Questionnaire: Social and Emotional (ASQ:SE) are the most commonly used 

developmental screening tools. 

•	 Grantees most commonly track performance by reporting rates of screening, 

while some track referrals to service providers or discussion of screening 

results. 
144 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Benchmark Domain 4: Crime or Domestic Violence 

•	 Performance measurement guidelines allowed grantees to choose to measure 

either crime or domestic violence. All 25 grantees chose to assess domestic 

violence in their benchmark plans. 

•	 All grantees use process measures to track the three domestic violence 

constructs. 

•	 While all grantees chose to examine screening for domestic violence, 

programs use a variety of screening instruments. Grantees use seven different 

domestic violence screening instruments, and five grantees chose to use a 

nonstandardized measure. 

Benchmark Domain 5: Family Economic Self-Sufficiency 

•	 All grantees use outcome measures to assess economic self-sufficiency 

(Construct 5.1–5.3). In all but one case, this information is provided through 

participant self-report. 

•	 Grantees chose to measure income and benefits (Construct 5.1) in a variety of 

ways. Just under half of grantees (48 percent, n=12) use a standardized selfreport measure of economic security rather than income. Forty-four percent 

(n=11) are examining changes in income. 

•	 Grantees chose to examine employment or education (Construct 5.2) in a 

variety of ways. The largest number of grantees (40 percent, n=10) chose 

to measure the number of hours spent participating in either educational or 

employment activities. 

Benchmark Domain 6: Coordination and Referrals 

for Other Community Resources 

•	 All grantees chose to use process measures to examine identification for 

services, referrals, number of MOUs, and information sharing (Constructs 

6.1–6.4), and all grantees chose an outcome measure to examine receipt of 

services (Construct 6.5). 

•	 Grantees use a variety of approaches for identifying necessary services 

(Construct 6.1). A majority (60 percent, n=15) screen for a comprehensive 

array of needs. Other grantees focus on a limited set of needs (16 percent, 

n=4) or on a single need (24 percent, n=6). 

•	 Grantees are measuring information sharing in a variety of ways. The majority 

of grantees (84 percent, n=21) are determining whether the home visiting 

program has a clear point of contact within the partnering agency. 
SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 145 

Summary of Benchmark Constructs With

the Highest Degree of Similarity 

•	 Breastfeeding: Grantees consistently chose to use an outcome measure for 

this construct. The majority of performance measures capture duration of 

breastfeeding (84 percent, n=21) rather than initiation of breastfeeding 

(16 percent, n=4). 

•	 Well-Child Visits: All grantees chose to assess this construct with an 

outcome measure (n=25). The majority of these outcome measures focus on 

adherence to a recommended well-child visit schedule (88 percent, n=22). 

•	 Child and Mother Visits to Emergency Department: All but one grantee (94 

percent) are using an outcome measure to capture visits to the emergency 

department, relying on parent self-report of visits. 

•	 Information/Training on Prevention of Child Injuries: All grantees are using 

a process measure to capture information and training on the prevention 

of child injuries, with most (92 percent, n=23) focusing on the provision of 

information about child injuries. 

•	 Child Injuries: All grantees are using an outcome measure for child injuries. 

Most grantees are relying on parent self-report (96 percent, n=24) of injuries. 

•	 Child Communication, Language, and Emergent Literacy: Most grantees 

(92 percent, n=23) are using the ASQ-3 to screen for developmental concerns 

related to child communication. 

•	 Child Cognitive Skills: Most grantees (92 percent, n=23) are using the ASQ-3 

to screen for delays related to child cognitive skills. 

•	 Number of Memoranda of Understanding (MOU) To Increase Coordination 

of Resources and Referrals: All grantees are counting the number of MOUs 

developed between the home visiting program and outside partners. 

Summary of Benchmark Constructs With

the Highest Degree of Diversity 

•	 Alcohol, Tobacco, and Illicit Drugs: Grantees are divided in their use of a 

process or outcome measure to assess this construct. Fifty two percent (n=13) 

chose an outcome measure, and the remainder (48 percent, n=12) chose a 

process measure. Grantees use a variety of tools to screen for substance use. 

Grantees use seven different measures focused on either a single substance or 

a combination of alcohol, tobacco, and illicit drugs. 

•	 Inter-Birth Intervals: There is considerable variation in the use of a process or 

outcome measure for this construct. Over half of grantees (56 percent, n=14) 
 

146 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

are using a process measure, such as provision of information. Forty-four 

percent (n=11) are using an outcome measure, including contraception use or 

pregnancy spacing. 

•	 Parent Support for Child Learning and Development: While most grantees 

chose to use an outcome measure (92 percent, n=23), there is significant 

variation in the instruments they chose to measure this construct. Grantees 

selected six different measures. 

•	 Child Physical Health and Development: Over half (64 percent, n=16) of grantees 

are using a process measure to assess child physical health and development. 

There is significant variation in the defined performance measures. 

•	 Screening for Domestic Violence: While all grantees are screening for 

domestic violence, they are using a wide range of screening tools. Grantees 

use seven unique screening instruments. 

CONSTRUCT-SPECIFIC SUMMARIES 

Below is a brief summary of grantee performance measures across the 36 benchmark 

constructs, including how they aligned across type of measure (process or outcome), 

focus of performance measure, target population, and tools/measures used. 

Benchmark Domain 1: Maternal, Newborn, and Child Health 

Construct 1.1: Prenatal Care 

•	 All 25 grantees are using an outcome measure to assess prenatal care among 

pregnant participants. 

•	 The majority of the performance measures focus on the adequacy of prenatal 

care (64 percent, n=16), with a minority focused on the onset of prenatal care 

(32 percent, n=8). One grantee is measuring both adequacy and onset 

(4 percent). 

•	 Of the 16 grantees that are measuring adequacy, most (88 percent, n=14) 

are measuring the percentage of recommended prenatal care visits received; 

two (13 percent) are measuring the completion of visits within a specified 

timeframe (e.g., receipt of one visit in each trimester). 

•	 Of the eight grantees measuring the onset of prenatal care, half (n=4) are 

measuring onset during the first trimester and half (n=4) are measuring onset 

more generally. 

•	 Ninety-six percent (n=24) of grantees are using self-report to capture these 

data, with the remaining four percent (n=1) using administrative data. 
SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 147 

Construct 1.2: Alcohol, Tobacco, and Illicit Drugs
 

•	 Over half of grantees (52 percent, n=13) are relying on outcome measures to 

measure substance use, while 48 percent (n=12) are using process measures. 

Performance measures focus on the use of tobacco (48 percent, n=12); 

alcohol (24 percent, n=6); or some combination of alcohol, tobacco and illicit 

drugs (28 percent, n=7). 

•	 Over half of grantees are using a standardized tool to collect the data. 

However, there is very little alignment across the standardized tools identified: 

16 percent (n=4) are using the Life Skills Progression (LSP); 12 percent (n=3) 

are using the CAGE; and eight percent (n=2) are using the Alcohol Use 

Disorders Identification Test (AUDIT). Instruments used by one grantee each 

include UNCOPE, CRAFFT, Drug Abuse Screening Test (DAST), and Institute for 

Health and Recovery Integrated Screener (IHRIS). 

•	 A majority (68 percent, n=17) of grantees are assessing all mothers/caregivers 

enrolled, while a minority (32 percent, n=8) are targeting only pregnant 

mothers for this performance measure. 

Construct 1.3: Preconception Care 

•	 Seventy-six percent (n=19) of grantees are using outcome measures to 

capture preconception care, while 24 percent (n=6) are using process 

measures. 

•	 Performance measures focus on postpartum checkups (36 percent, n=9), 

provision of information on preconception care (24 percent, n=6), routine 

preventive or well-women exams (16 percent, n=4), folic acid or other vitamin 

supplement use (8 percent, n=2), contraception use (8 percent, n=2), or report 

of a medical home (8 percent, n=2). 

•	 More than half (56 percent, n=14) of these performance measures target only 

postpartum mothers, with the remaining measures targeting all mothers or 

caregivers enrolled (44 percent, n=11). 

Construct 1.4: Inter-Birth Intervals 

•	 Fifty-six percent (n=14) of grantees are using process measures, and 

44 percent (n=11) are using outcome measures to assess this construct. 

•	 Of those grantees using a process measure, the majority (86 percent, 

n=12) are focusing on the provision of information related to birth spacing; 

two grantees (14 percent) are examining completion of a reproductive life 

plan. 
148 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

•	 Of those using an outcome measure, 64 percent (n=7) are tracking 

contraception use, 27 percent (n=3) focus on pregnancy spacing, and one 

grantee is tracking receipt of a postpartum or well-woman exam (9 percent). 

•	 Twenty-eight percent (n=7) of grantees are assessing this construct among 

postpartum women, whereas 72 percent (n=18) are assessing all mothers/ 

caregivers. 

Construct 1.5: Maternal Depressive Symptoms 

•	 All 25 grantees are relying on process measures to capture screening of 

maternal depressive symptoms, with 96 percent (n=24) focusing on the rates 

of screenings and four percent (n=1) on referral rates for those participants 

screened positive for depressive symptoms. 

•	 Forty percent (n=10) of the performance measures target only postpartum 

mothers enrolled in the program; 56 percent (n=14) of performance 

measures target all mothers; and four percent (n=1) target only pregnant 

mothers. 

•	 The most common tools identified for the screening of depressive symptoms 

include the Edinburg Postnatal Depression Scale (EPDS) (72 percent, n=18), 

followed by the Patient Health Questionnaire-9 (PHQ-9) (12 percent, 

n=3), Patient Health Questionnaire-2 (PHQ-2) (8 percent, n=2), Center for 

Epidemiologic Studies Depression Scale (CES-D) (8 percent, n=2), the IHRIS 

(4 percent, n=1), and LSP (4 percent, n=1). 

Construct 1.6: Breastfeeding 

•	 All 25 grantees are using outcome measures to assess improvement in 

breastfeeding. 

•	 While the majority (84 percent, n=21) of performance measures focus 

on the duration of breastfeeding, there is variation in how duration is 

operationalized. Most grantees are tracking the average number of weeks 

mothers spend breastfeeding (48 percent, n=12), while others focus on the 

duration of breastfeeding at less than two months (8 percent, n=2) and at six 

months (28 percent, n=7) postpartum. 

•	 In addition to duration, 16 percent (n=4) of grantees are measuring whether 

mothers initiated breastfeeding at all. 

Construct 1.7: Well-Child Visits 

•	 One hundred percent of grantees are measuring well-child visits using an 

outcome measure (n=25). 
SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 149 

•	 Twenty-two out of 25 grantees (88 percent) are measuring adherence to a 

recommended well-child visit schedule, while three grantees (12 percent) are 

measuring immunizations. 

•	 Most grantees (88 percent, n=22) are using self-report to capture well-child 

visits, while a minority (12 percent, n=3) are using administrative data (e.g., 

electronic health records). 

Construct 1.8: Regular Visits to a Primary Healthcare 

Provider or Medical Home 

•	 All 25 grantees are using an outcome measure to assess this construct. 

•	 Seventy-six percent (n=19) are tracking visits to a primary care provider, 

20 percent (n=5) are assessing report of a medical home, and four percent 

(n=1) are tracking postpartum care. 

•	 Forty-eight percent of grantees (n=12) are targeting the mother and child, 

40 percent (n=10) are targeting all mothers/caregivers, eight percent (n=2) 

are focusing on the child alone, and four percent (n=1) are targeting only 

postpartum mothers. 

Construct 1.9: Maternal and Child Health Insurance Status 

•	 Grantees are predominantly using outcome measures to assess improvement 

in maternal and child health insurance status (92 percent outcome, n=23; 

8 percent process, n=2). 

•	 All grantees using process measures are tracking referrals made by home 

visitors to insurance providers (8 percent, n=2). 

•	 Of those using outcome performance measures, most focus on the health 

insurance status of both the mother and child (86 percent, n=20), with a 

few tracking the status of the mother only, the child only, or the number of 

months insured (for each, 4 percent, n=1). 

Benchmark Domain 2: Child Injuries; Child Abuse, Neglect, or

Maltreatment; and Emergency Room Visits 

Construct 2.1: Visits for Children to Emergency Department 

•	 All but one grantee (96 percent, n=24) is relying on outcome measures to 

assess improvement in visits for children to the emergency department (ED). 

•	 Measures focus on the number of children with visits to the ED (48 percent, 

n=12) or the incidents/number of visits to the ED (44 percent, n=11), 

demonstration of knowledge through pre/posttests (4 percent, n=1), or 
150 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

provision of information about when to seek treatment for a child in the ED 

(4 percent, n=1). 

•	 Only one grantee (4 percent) is using administrative data for this construct. 

Others are using self-report (88 percent, n=22) or program documentation 

(8 percent, n=2). 

Construct 2.2: Visits for Mothers to Emergency Department 

•	 All but one grantee (96 percent, n=24) is using outcome measures to assess 

visits for mothers to the ED. 

•	 Measures focus on the number of mothers with visits to the ED (56 percent, 

n=14), incidents/number of visits to the ED (40 percent, n=10), or provision of 

information about when to seek treatment in the ED (4 percent, n=1). 

•	 Most grantees are collecting data via self-report through interview 

questions and program forms (96 percent, n=24). Only one grantee is using 

administrative data (i.e., hospital or health records). 

•	 All but one grantee (96 percent) are targeting all mothers/caregivers; the 

remaining grantee is targeting only pregnant mothers (4 percent). 

Construct 2.3: Information/Training on Prevention of Child Injuries 

•	 All 25 grantees are using process measures to track the provision of information 

and training on the prevention of child injuries through program documentation. 

•	 The vast majority of measures focus on the provision of information about the 

prevention of child injuries (92 percent, n=23). Two grantees (8 percent) are 

focusing on the completion of a home safety checklist with families. 

Construct 2.4: Child Injuries 

•	 All 25 grantees are using an outcome measure to capture child injuries. 

•	 The measures focus on the number of children with injuries (72 percent, n=18) 

and the number of incidents of injuries (26 percent, n=7). 

•	 Most grantees are collecting data via parent self-report (96 percent, n=24). 

One grantee is using administrative data (health records) (4 percent). 

Construct 2.5: Reported Suspected Maltreatment 

•	 All 25 grantees are relying on outcome measures for reports of suspected 

child maltreatment. 

•	 The measures focus on the number of children with reports of suspected 

maltreatment (76 percent, n=19) and the number of reports of suspected 
SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 151 

maltreatment (24 percent, n=6). Over half of the grantees (56 percent, n=14) 

are receiving administrative data from the child welfare agency. Ten grantees 

(40 percent) are relying on parent self-report, and one grantee is using 

program documentation (4 percent). 

Construct 2.6: Reported Substantiated Maltreatment 

•	 All 25 grantees are using an outcome measure to track substantiated reports 

of child maltreatment. 

•	 The measures focus on the number of children with substantiated reports of 

maltreatment (80 percent, n=20) and the number of substantiated reports of 

maltreatment (20 percent, n=5). 

•	 Sixty percent of grantees are using administrative data from the child welfare 

agency (n=15), and 40 percent are relying on parent self-report (n=10). 

Construct 2.7: First-Time Victims of Maltreatment 

•	 All 25 grantees are using an outcome measure to assess first-time victims of 

child maltreatment. 

•	 All grantees are focusing on the number of children who are first-time victims 

of child maltreatment. 

•	 Sixty percent of grantees are collecting administrative data from the child 

welfare agency (n=15), and 40 percent are relying on parent self-report 

(n=10). 

Benchmark Domain 3: School Readiness and Achievement 

Construct 3.1: Parent Support for Child Learning and Development 

•	 Ninety-two percent (n=23) of grantees are using outcome measures to track 

performance in parent support for child learning and development. Eight 

percent (n=2) are using a process measure. 

•	 Grantees are using an array of instruments, with the most common 

instrument selected for this construct being the Home Observation for 

the Measurement of the Environment (HOME) (28 percent, n=7). Other 

instruments selected include the Life Skills Progression (LSP) (12 percent, 

n=3), Parenting Interactions with Children Checklist of Observations 

Linked to Outcomes (PICCOLO) (12 percent, n=3), University of Idaho 

Survey of Parenting Practices (UISPP) (12 percent, n=3), Ages and Stages 

Questionnaire-3 (ASQ-3) (8 percent, n=2), and Keys to Interactive Parenting 

Scale (KIPS) (8 percent, n=2). 
152 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Construct 3.2: Parent Knowledge of Child Development 

•	 Seventy-two percent (n=18) of grantees are using outcome measures to asses 

parent knowledge of child development. Twenty-eight percent (n=7) are using 

process measures. 

•	 The instrument chosen most frequently was the ASQ-3 (24 percent, n=6), 

followed by the HOME (20 percent, n=5). Other instruments selected include 

the Family Spirit Knowledge Assessment (12 percent, n=3), KIPS (8 percent, 

n=2), LSP (8 percent, n=2), and UISPP (8 percent, n=2). An additional three 

instruments have been selected by one grantee each. 

•	 All grantees selecting process performance measures focused on the provision 

of information about the child’s developmental progress (i.e., home visitor 

reviewing the results of the ASQ-3 with the parent) (28 percent, n=7). 

Construct 3.3: Parenting Behaviors/Parent-Child Relationship 

•	 Most grantees (88 percent, n=22) are using outcome measures to assess 

improvement in parenting behaviors or the parent–child relationship. Twelve 

percent (n=3) are using process measures. 

•	 Grantees are using a variety of instruments including the HOME (24 percent, 

n=6), KIPS (12 percent, n=3), LSP (12 percent, n=3), PICCOLO (16 percent, n=3), 

and UISPP (12 percent, n=3). An additional six measures have been selected 

by one grantee each. 

•	 Grantees selected the following process measures: discussion of 

developmental screening results (4 percent, n=1), completion of parental 

stress assessment (4 percent, n=1), and participation in group sessions 

focused on parent–child attachment (4 percent, n=1). 

Construct 3.4: Parent Emotional Well-Being/Parenting Stress 

•	 Over half (52 percent, n=13) of the 25 grantees are using process measures to 

assess parent emotional well-being or parenting stress. 

•	 Thirty-two percent (n=8) are measuring the percentages that were screened 

for depression, and 24 percent are measuring the level of depression (n=6). 

Twenty percent (n=5) are tracking the percentage that completed assessments 

of parenting stress, and 16 percent (n=4) are measuring the level of parental 

stress. One grantee (4 percent) is tracking referrals made to mental health 

providers. 

•	 A wide variety of tools are being used to assess this construct, including the 

Edinburg Postnatal Depression Scale (EPDS) (48 percent, n=12), the Parenting 

Stress Index (20 percent, n=5), the Patient Health Questionnaire (20 percent, 
SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 153 

n=5), the Protective Factors Survey (8 percent, n=2), the LSP (4 percent, n=1), 

and the Parental Stress Scale (4 percent, n=1).27 

 Some grantees used more than one instrument, so the total exceeds 100 percent. 

•	 Twenty-eight percent (n=7) of grantees are assessing parent emotional wellbeing or parenting stress for postpartum women only, whereas 72 percent 

(18) are assessing the construct for all mothers or caregivers. 

Construct 3.5: Child Communication, Language, and Emergent Literacy 

•	 Seventy-two percent (n=18) of grantees are using process measures to assess 

child communication, language, and emergent literacy, and 28 percent (n=7) 

are using outcome measures. 

•	 Ninety-two percent (n=23) chose to use the ASQ-3; one grantee selected the 

Survey of Wellbeing in Young Children (SWYC) (4 percent); and one selected 

the Newborn Behavioral Observation instrument (NBO) (4 percent). 

•	 Of the grantees using a process measure, 89 percent (n=16) are tracking 

developmental screenings, four percent (n=1) are tracking referrals, and four 

percent (n=1) are tracking whether the results of the developmental screening 

were discussed. 

Construct 3.6: Child Cognitive Skills 

•	 Of the 25 grantees, 72 percent (n=18) are using process measures to assess 

child cognitive skills and 28 percent (n=7) are using outcome measures. 

•	 Ninety-two percent (n=23) chose to use the ASQ-3; one grantee selected the 

SWYC (4 percent); and one selected the NBO (4 percent). 

•	 Of the grantees using process measures, 89 percent (n=16) are tracking 

developmental screenings, four percent (n=1) are tracking referrals, and four 

percent (n=1) are tracking whether the results of the developmental screening 

were discussed. 

Construct 3.7: Child Positive Approaches to Learning 

•	 To assess improvement in positive approaches to learning among children, 

68 percent of grantees are using process measures (n=17) and 32 percent 

(n=8) are using outcome measures. 

•	 Sixty-four percent are tracking screening for developmental delay (n=16), 

32 percent (n=8) are measuring developmental outcomes, and one grantee is 

tracking referrals (4 percent). 

27
154 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

•	 Among tools selected by grantees to measure this construct, 88 percent chose 

the ASQ-3 (n=22). The following measures were selected by one grantee 

each: Ages and Stages Questionnaire: Social-Emotional (ASQ-SE) (4 percent), 

the NBO (4 percent), and the SafeCare Infant Planned Activities Training 

(4 percent). 

Construct 3.8: Child Social Behavior/Emotional Well-Being 

•	 Most grantees (80 percent, n=20) are using process measures to assess child 

social behavior/emotional well-being; the remaining five grantees (20 percent) 

are using outcome measures. 

•	 Of those using process measures 18 out of 20 (90 percent) are examining 

screening rates; the remaining two grantees (10 percent) are tracking 

referrals. 

•	 The most common tool used to assess child social behavior/emotional wellbeing is the ASQ-SE (60 percent, n=15). The ASQ-3 was the second most 

commonly selected tool, with 28 percent of grantees (n=7) selecting this tool. 

The following tools were selected by one grantee (4 percent) each: NBO, 

Child Behavior Checklist, and Baby Pediatric Symptoms Checklist/Preschool 

Pediatric Symptom Checklist. 

Construct 3.9: Child Physical Health and Development 

•	 Of the 25 grantees, 64 percent (n=16) are using process measures to assess 

child physical health and development, and 36 percent (n=9) are using 

outcome measures. 

•	 There is a wide range of performance measures for this construct. Of those 

using a process measure, grantees are measuring screenings for gross and 

fine motor development using the ASQ-3 (81 percent, n=13); more general 

assessments of health and physical development (13 percent, n=2); screenings 

for height, weight, and head circumference (13 percent, n=2); and receipt of 

intervention services (4 percent, n=1). 

•	 Of those using an outcome measure, three grantees (33 percent) are 

measuring general health and physical development; three grantees (33 

percent) are tracking height, weight, and head circumference; and one 

grantee (11 percent) is tracking immunizations. 

•	 Fifteen grantees (60 percent) are using the ASQ-3. The following instruments 

are used by one grantee (4 percent) each: NBO, SWYC, PAT Health Record, and 

Infant Health Form. The remaining grantees (24 percent, n=6) are not using a 

standardized measure. 
 

SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 155 

Benchmark Domain 4: Crime or Domestic Violence 

Construct 4.1: Screening for Domestic Violence 

•	 All 25 grantees chose to report on the domestic violence constructs 

(screenings, referrals, and safety plans) rather than crime (arrests and 

convictions). 

•	 One hundred percent of grantees are using process measures, capturing 

screening for domestic violence. 

•	 Most of the process measures track the number of women screened for 

domestic violence (92 percent, n=23). Eight percent are tracking the number 

of screenings conducted (n=2). 

•	 Grantees are using a wide range of tools to screen for domestic violence: 

28 percent (n=7) are using the Women’s Experience with Battering 

instrument (WEB); 28 percent (n=7) are using the Adult Abuse Screener 

(AAS); 12 percent (n=3) are using the Nurse Family Partnership Relationship 

Assessment Form; eight percent (n=2) are using the Woman Abuse 

Screening Tool (WAST); four percent (n=1) are using the Domestic Violence 

Ended instrument; four percent (n=1) are using the IHR Integrated Screening 

Tool; and four percent (n=1) are using the DV/IPV Questionnaire. Five 

grantees (20 percent) are using a program form or a nonstandardized 

instrument. 

Construct 4.2: Referrals for Domestic Violence Services 

•	 All 25 grantees are relying on process measures to assess improvement in 

referrals for domestic violence services for those participants who screen 

positive for domestic violence. 

•	 Eighty-eight percent of grantees (n=22) are reporting on the percentage of 

participants referred for domestic violence services, while 12 percent (n=3) 

are reporting on the number of referrals made. 

Construct 4.3: Domestic Violence Safety Plan 

•	 All 25 grantees are using process measures to track the completion of 

domestic violence safety plans created for those participants who screen 

positive for domestic violence. 

•	 Eighty-eight percent of grantees (n=22) are reporting on the percentage of 

participants with safety plans, while 12 percent (n=3) are reporting on the 

number of safety plans completed. 
 

156 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Benchmark Domain 5: Family Economic Self-Sufficiency 

Construct 5.1: Income and Benefits 

•	 All 25 grantees are using an outcome performance measure, relying on 

participant self-report. 

•	 Half of grantees (48 percent, n=12) are using a self-report measure of 

economic security as a proxy for income. Forty-four percent (n=11) are 

measuring income: 12 percent (n=3) from all sources of income and 

32 percent (n=8) from income and benefits alone. 

•	 Two grantees (8 percent) are capturing receipt of concrete supports. 

•	 Grantees are assessing household/family members (48 percent, n=12), mothers/ 

caregivers (48 percent, n=12), or pregnant women only (4 percent, n=1). 

Construct 5.2: Employment or Education 

•	 One hundred percent (n=25) of grantees are using outcome measures, relying 

on participant self-report. 

•	 Grantees are using a wide variety of performance measures for this construct. 

Fifty-six percent (n=14) are tracking employment and education combined, 

28 percent (n=7) are measuring education, and 16 percent (n=4) are tracking 

employment alone. 

•	 Performance measures focusing on employment and education combined 

are measuring the total number of hours spent working, in job training, 

or educational activities (40 percent, n=10) and the number of enrollees 

participating in employment or educational activities (16 percent, n=4). 

•	 Performance measures that assess education alone measure attainment 

of a diploma, GED, or certification (20 percent, n=5) and participation in 

educational activities (8 percent, n=2). 

•	 Performance measures capturing employment alone assess paid hours worked 

(12 percent, n=3) and employment status (4 percent, n=1). 

•	 Grantees are targeting household/family members (40 percent, n=10), mothers/ 

caregivers (25 percent, n=14), or pregnant women only (4 percent, n=1). 

Construct 5.3: Health Insurance Status 

•	 All 25 grantees are assessing health insurance status using an outcome 

measure, primarily through participant self-report (96 percent, n=1). 

•	 Most grantees are assessing health insurance status of mothers and children 

(80 percent, n=20), followed by household status (8 percent, n=2), child’s 

status (8 percent, n=2), and the status of the mother alone (4 percent, n=1). 
SUMMARY OF TRIBAL MIECHV BENCHMARK PERFORMANCE MEASURES 157 

Benchmark Domain 6: Coordination and Referrals 

for Other Community Resources and Supports 

Construct 6.1: Identification for Necessary Services 

•	 All grantees are using process measures for identification of necessary 

services. 

•	 Sixty percent (n=15) of grantees are focusing on comprehensive screening of 

needs, 24 percent (n=6) on screening for a single need, and 16 percent (n=4) 

on screening for a limited set of needs (e.g., domestic violence, maternal 

depression, developmental delay). 

•	 Forty eight percent (n=12) of grantees are assessing multiple family or 

household members. The same number of grantees (n=12) is focusing on 

the mother or caregiver, and four percent (n=1) are focused on screening of 

children. 

Construct 6.2: Referrals for Necessary Services 

•	 All grantees are using process measures, with program documentation 

providing information on rates of service referrals. 

•	 Eighty-four percent (n=21) are tracking the number of families referred, and 

16 percent (n=4) are tracking the number of individual referrals made. 

Construct 6.3: Number of MOUs 

•	 All 25 grantees chose to report on a process measure for the number of MOUs 

with community agencies, and all are reporting a simple count of MOUs at 

two time points. 

Construct 6.4: Information Sharing 

•	 All 25 grantees are using process measures to report on information 

sharing with community agencies, with 24 of 25 grantees (96 percent) 

reporting a simple count and one grantee (4 percent) reporting a 

percentage. 

•	 The majority of grantees proposed having a clear point of contact in 

another agency (84 percent, n=21) as the indicator for this construct. Other 

indicators for this construct include agencies with which the grantee shares 

information (4 percent, n=1), collaborative meetings (4 percent, n=1), 

agencies with which the client has authorized release and exchange of 

information (4 percent, n=1), and agencies that receive referrals from home 

visitors (4 percent, n=1). 
158 TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING: A REPORT TO CONGRESS

Construct 6.5: Receipt of Necessary Services 

•	 All 25 grantees are measuring completion of referrals to external service 

providers, which is defined as an outcome measure. 

•	 Sixty percent (n=15) of grantees are assessing the number of completed 

referrals, while 40 percent (n=10) are assessing the number of families who 

received necessary services. 

Definitions of Key Terms28 

 Key term definitions draw from (1) U.S. Department of Health and Human Services, Administration for Children 

and Families, Office of Child care (2014). Tribal Maternal, Infant, and Early Childhood Home Visiting Program Guidance 

for Submitting a Needs Assessment and Plan for Responding to Identified Needs; and (2) U.S. Department of Health 

and Human Services, Administration for Children and Families, Office of Planning Research and Evaluation (2011). 

Design Options for Home Visiting Measurement Brief: Selecting Data Collection Measures for MIECHV Benchmarks. 

http://www.mdrc.org/sites/default/files/img/DOHVE%20Measurement%20Brief.pdf. 

Term Definition 

Benchmark An indicator used to track quantifiable improvement. Benchmarks may also be 

called measures or performance measures. 

Construct The concept to be measured. In the case of Tribal MIECHV, the 36 benchmark 

constructs were predetermined. 

Benchmark 

domain 

Each benchmark construct is grouped into six benchmark areas: 

(1) improvements in maternal, newborn, and child health; (2) prevention 

of child injuries, child abuse, neglect, or maltreatment, and reduction 

of emergency room visits; (3) improvements in school readiness and 

achievement; (4) reductions in crime or domestic violence; (5) improvements 

in family economic self-sufficiency; and (6) improvements in the coordination 

and referrals for other community resources and supports. 

Process 

measure 

Process measures capture program services and activities, programmatic 

policies, and procedures implemented. 

Outcome 

measure 

Outcome measures track change at the individual child, family, and system 

level. Outcome data are often collected to assess improvements or changes in 

participant knowledge, attitudes, skills, or behaviors. 

Alignment The degree of similarity between grantee benchmark measures. 

28
Aleta Meyer, Project Officer 

Office of Planning, Research and Evaluation 

Administration for Children and Families 

U.S. Department of Health and Human Services 

http://www.acf.hhs.gov/programs/opre 

Contract Number: HHSP23320095644WC 

Project Director: Kate Lyon 

James Bell Associates, Inc. 

3033 Wilson Boulevard Suite 650 

Arlington, VA, 22201 

This report is in the public domain. Permission to reproduce it is not necessary. Suggested citation: Lyon, 

K., Geary, E., Sparr, M., Buckless, B., Salvador, M., & Morales, J. (2015). Tribal Maternal, Infant, and Early 

Childhood Home Visiting: A report to Congress (OPRE Report #2015-88). Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and 

Human Services. 

This report and other reports sponsored by the Office of Planning, Research and Evaluation are available 

at http://www.acf.hhs.gov/programs/opre/index.html. 
Administration for Children and Families

U.S. Department of Health and Human Services

330 C Street, SW

Washington, DC 20201