Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program: Background and Funding
Released: 2018-11-21T00:00:00

Introduction

Early childhood home visiting is a strategy for delivering services to improve health, well-being, and education outcomes for vulnerable families with young children. Nurses, social workers, and other professionals visit the homes of families who participate on a voluntary basis. The federal government has long supported early childhood programs in which home visiting is a major component or is otherwise permitted. The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is the primary federal program that focuses exclusively on home visiting. The program was implemented in March 2010, following the Obama Administration's budget request for a national home visiting program and a home visitation pilot program carried out in 15 states that had been initiated by the George W. Bush Administration. Congress considered proposals to establish home visiting programs as part of health care reform in 2010 and in prior years.

HHS provides MIECHV funding to states, territories, and tribal entities for home visiting services in at-risk communities, as identified by these jurisdictions. MIECHV prioritizes certain populations, including low-income families, young mothers, or individuals who have a history of substance abuse, among other risk factors. Families participate on a voluntary basis. In FY2017, the MIECHV program served 156,297 individual parents and children who participated in 942,676 home visits. Jurisdictions that carry out home visiting programs under the program must adhere to specific requirements. For example, they must use most of their program funding to implement one or more home visiting models that have been identified by HHS to be effective. Separately, HHS provides training and technical assistance to jurisdictions and is carrying out research activities to evaluate the impacts of the program on participants' outcomes.

This report begins with an overview of the MIECHV program and home visiting generally, and discusses federal efforts to increase and support home visiting services. It goes on to describe the program, including information about its administration, coordination, and funding. Following this is an outline of MIECHV requirements for states and other jurisdictions, including information on the types of home visiting models that have been implemented across jurisdictions. The report concludes with information about efforts to research, evaluate, and provide technical assistance within the MIECHV program.

Appendix A includes federal legislative history on home visiting; Appendix B includes funding levels by state for the MIECHV program in selected years; Appendix C includes a timeline of relevant dates for the program; and Appendix D provides information about home visiting models adopted by jurisdictions, and features of selected home visiting models that meet HHS criteria for being effective.

Overview of Home Visiting

What is Home Visiting?

Home visiting is a holistic strategy that involves social, health, and/or educational services for parents and their children from birth to entry into kindergarten. In practice, it generally entails visits to the homes of families on a regular basis (e.g., weekly or monthly) over an extended period (e.g., six months or longer). For some home visiting models, the number of visits becomes more infrequent over time. Depending on the program model, visits may be conducted by nurses, mental health clinicians, social workers, or paraprofessionals who have received specialized training. These visitors provide services such as parenting education and they refer families to other services in the community.

To a large extent, parents shape their children's earliest experiences. Home visiting programs seek to help parents better understand the development of their children. For example, home visitors can help parents facilitate learning opportunities through playing games, talking to their children frequently, and reading to them. Home visitors can also provide information to parents about child health, such as the value of well-child visits, car seat safety, and brushing teeth. Home visiting can directly help parents identify outside supports, such as referrals for health insurance and substance abuse resources. The programs can help achieve positive benefits for children, parents, and possibly their communities.

For many years, greater attention has been focused on early childhood home visitation as a way to improve child and family outcomes. In recent decades, this trend appears to be driven in some part by newer research on how the human brain develops and, specifically, the significance of prenatal and early childhood environments to later life.

Research on Home Visiting

At least since the 1960s, a variety of early childhood home visiting models have undergone many assessments and evaluations intended to test how effectively they achieve their goals. Looking at findings across multiple home visiting studies, researchers conclude that home visiting can provide benefits to children and their parents, including preventing potential child abuse and neglect, enhancing cognitive development, improving parenting attitudes and parenting behaviors (e.g., discipline strategies), and increasing maternal education. They caution, however, that while visiting programs can lead to improvements, the difference is small between observed outcomes for families that received home visits versus those who did not. Further, while one or more individual studies may have shown positive effects with regard to the desired outcomes, those effects have not necessarily been studied and/or achieved across more than one study or program site. Nonetheless, some models or aspects of models have been shown to be particularly effective. Overall, while researchers have cautioned that home visiting is not a panacea, they have generally encouraged its implementation as part of a range of strategies intended to enhance and improve early childhood development.

Overview of the MIECHV Program

The Patient Protection and Affordable Care Act (ACA, as amended; P.L. 11-148) established the MIECHV program under Section 511 of the Social Security Act. (See Appendix A for a history of federal home visiting efforts.) The program—jointly administered by the U.S. Department of Health and Human Services' (HHS's) Health Resources and Services Administration (HRSA) and Administration for Children and Families (ACF)—seeks to strengthen and improve home visiting services and support to families residing in at-risk communities, while also referring families to services outside of the program. States, territories, and Indian tribes determine which communities are at risk by conducting needs assessments.

The MIECHV law requires that jurisdictions administer programs that are evidence-based. Specifically, jurisdictions must use no less than 75% of their program funds to implement home visiting models that HHS has determined as effective, ensure that services are carried out with fidelity to these program models, and demonstrate improvements in outcomes for participating families.

MIECHV funding is mandatory, meaning that the authorizing law funds the program directly (as opposed to the funding provided through appropriations law). Annual funding levels have been between $100 million and $400 million. The most recent reauthorization of the program, the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123 ) extended funding through FY2022. With limited exceptions, jurisdictions have two full fiscal years to expend these funds.

The law includes several requirements related to eligible families, funding program administration, and research and evaluation. Figure 1 summarizes the major components of the program.

Eligible Families

Under the MIECHV program, jurisdictions provide home visiting services to eligible families who volunteer to participate. An eligible family includes (1) a woman who is pregnant, and the father-to-be, if available; (2) a parent or primary caregiver of a child, including grandparents or other relatives of the child, and foster parents, who is serving as the child's primary caregiver from birth to entry into kindergarten; and (3) a noncustodial parent who has an ongoing relationship with, and at times provides physical care for, the child from birth to entry into kindergarten. Jurisdictions must give priority to serving eligible families who meet any of the following criteria:

reside in communities that are in need of home visiting services, as identified in the needs assessment conducted by the jurisdiction and accounting for other factors (staffing, community resources, and other requirements) that are necessary to operate at least one approved home visiting model in those communities; are low-income; include a pregnant woman under the age of 21; have a history of child abuse or neglect or have had interactions with child welfare services; have a history of substance abuse or need substance abuse treatment; have users of tobacco products in the home; have children with low student achievement; have children with developmental delays or disabilities; or individuals who are serving, or formerly served, in the Armed Forces, including such families that have members of the Armed Forces who have had multiple deployments outside of the United States.

Funding

Funding for the MIECHV program has increased over time from $100 million to $400 million annually. The authorizing law requires that 3% of the annual funding is to be reserved for Indian tribal entities, and another 3% is to be reserved for selected technical assistance, research, and evaluation. MIECHV funding may be expended by the jurisdiction through the end of the second succeeding fiscal year after the award.

The law does not specify how the funds are to be awarded, though the most recent reauthorization of the program under BBA 2018 included language that directs HHS to use the most accurate data available for eligible jurisdictions if funding is awarded on the basis of relative population or poverty considerations. In practice, HHS has distributed MIECHV funds by both formula and competitive grants to states and other jurisdictions.

Formula Funding

Formula funding is available annually for home visiting in the 50 states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, the Northern Mariana Islands, and American Samoa. The factors for allocating funds under the formula component have changed, effective with funding awarded with the FY2016 appropriation. HHS has noted that the funds are intended to both address the need for services and to reward jurisdictions for improved outcomes. Table 1 uses funding for FY2018 as an example of how formula funds are to be awarded. Funds are allocated, in part, based on a "need funding" factor that accounts for the relative share of children in poverty, with certain adjustments. Most of the funds will be allocated based on a "base funding" factor that accounts for the amount of competitive funding each jurisdiction receives. Awards are adjusted using "guard rails" to ensure no award varies by greater than ±7.5% from the prior-year formula ceiling amount.

Competitive Funding

In some years, HHS has awarded competitive funding to jurisdictions based on the strength of their program or their effort to develop a strong program. Most recently, HHS awarded competitive funding in FY2017 (using carryover funding from prior years). These "innovation grants" focused on bolstering selective aspects of home visiting (e.g., recruitment, engagement, and retention of eligible families). In the past, competitive funds were provided for "development grants" focused on building the capacity of the workforce, data infrastructure, and care coordination and referral systems; and/or to build upon their efforts already underway and expand services to more families and communities under grants known as "expansion grants."

Funding Levels

Funding levels for the program have been enacted by the authorizing law, and amendments to that law, as follows:

The ACA directly appropriated five years of funding for the MIECHV program: $100 million for FY2010, $250 million for FY2011, $350 million for FY2012, and $400 million for each of FY2013 and FY2014. The Protecting Access to Medicare Act of 2014 ( P.L. 113-93 ) provided $400 million for the program for the first half of FY2015 (October 1, 2014, through March 31, 2015). The Medicare Access and CHIP Reauthorization Act of 2015 ( P.L. 114-10 ) extended the $400 million made available under P.L. 113-93 through all of FY2015 (October 1, 2014, through September 30, 2015). In other words, the law allowed HHS to obligate FY2015 funds through the end of FY2015 but otherwise did not change the level of funding for FY2015. P.L. 114-10 also provided $400 million for each of FY2016 and FY2017 under the program. BBA 2018 extended funding of $400 million for the program for each of FY2017 through FY2022.

Table 2 summarizes the obligated funding for the program from FY2010 through FY2017. The total funding for each year does not equal the mandatory level established in the law due to sequestration (in FY2013, FY2014, and FY2017). In addition, some funds were not obligated for each of FY2011 through FY2017.

Coordination in the Community and at the Federal Level

Coordination within Jurisdictions

The MIECHV law includes several provisions that seek to ensure holistic services to families and promote coordination between agencies. For example, the law states that grants for home visiting programs are intended to improve specific family outcomes across a number of domains concerning health, emotional and physical well-being, and education. Related to this, jurisdictions carrying out MIECHV programs were required to conduct an initial needs assessment that was coordinated with needs assessments under other federal programs, including those pertaining to child abuse, early childhood education, and domestic violence. Jurisdictions are required to update the needs assessment by October 1, 2020. Jurisdictions must also establish and demonstrate improvements in coordinating with other community resources and supports.

Federal Coordination

The law requires coordination at the federal level between HRSA (specifically, the Maternal and Child Health Bureau) and ACF in (1) reviewing and analyzing the statewide needs assessments; (2) awarding MIECHV funds and overseeing the grants; (3) carrying out an evaluation of the program and an accompanying report; and (4) establishing advisory panels (as required in the law to review and make recommendations on the evaluation for the program and for providing assistance to jurisdictions that have not met expectations for performance). In practice, HRSA administers funding for the states and territories, and ACF administers funds for the tribes. ACF, in collaboration with HRSA, is overseeing the random assignment evaluation of the program known as "MIHOPE."

The law also specifies that HRSA and ACF must coordinate and collaborate on research with other federal agencies that have responsibility for administering or evaluating programs for eligible MIECHV families. Such agencies include the HHS Office for Planning and Evaluation (OPRE), the Centers for Disease Control and Prevention (CDC), the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (NIH), the Department of Justice's Office of Juvenile Justice and Delinquency Prevention (OJJDP), and the Department of Education's Institute of Education Sciences.

As of February 2020, HRSA and ACF must designate data exchange standards to ensure that a state agency operating a home visiting program can exchange data with another state agency under federal law. Additionally, HRSA and ACF must designate data exchange standards to govern federal reporting and data exchanges that are required under federal law. These standards are to be developed in consultation with a working group established by the Office of Management and Budget (OMB) and must consider the perspectives of states.

Administration

HHS formula and competitive grant funding for states and territories is allocated to a lead agency in each state that successfully applies for the MIECHV program. Jurisdictions are required to effectively implement home visiting models (or a single home visiting model) in the state's at-risk community or communities, as identified by the jurisdiction via its needs assessment.

States and territories can determine which lead agency or agencies will administer the MIECHV program. The public health department is the lead agency that administers home visiting funds in most states, the District of Columbia, and the five territories. In 13 of these jurisdictions (Alaska, Delaware, Guam, Idaho, Kentucky, Maine, Michigan, Montana, Nebraska, Nevada, New Hampshire, North Carolina, and West Virginia) the department of health also includes the state social service agency. In addition, 13 states administer the program through other departments with a social service focus (Alabama, Colorado, Connecticut, Illinois, Kentucky, Mississippi, New Mexico, Oregon, Pennsylvania, Texas, Vermont, Washington, and Wisconsin). South Carolina operates its program through a nonprofit organization, the Children's Trust Fund of South Carolina, which is authorized under state law and overseen by the state Office of Executive Policy and Programs.

Three states (Florida, North Dakota, and Wyoming) have declined funding for the program, and, as permitted under law, nonprofits have applied and have operated the program in these states in selected years: Florida Association of Healthy Start Coalitions (Florida); Prevent Child Abuse (North Dakota); and Parents as Teachers National Center (Wyoming). The nonprofit organizations receive funding that otherwise would have been awarded to the states in which they operate. To be eligible to operate home visiting programs under MIECHV, nonprofits must have an established record of providing early childhood home visiting programs or initiatives in one or more states.

Requirements for Grantees

Overview

The law specifies a variety of requirements for jurisdictions receiving MIECHV funds. These jurisdictions were required to conduct an initial needs assessment to identify communities with concentrations of poor infant health and mortality, poverty, and other negative outcomes. They had to submit the results of the assessments to HHS and explain how the jurisdiction intended to address the needs of the assessment. Under BBA 2018, jurisdictions must update their needs assessment. Further, the law requires jurisdictions to establish, subject to HHS approval, quantifiable and measurable benchmarks for demonstrating improvements in six indicators for eligible families in the program. Jurisdictions must also meet requirements related to serving families, among other requirements.

Needs Assessment

The MIECHV law requires states to conduct a statewide needs assessment for the MIECHV program. The law separately requires that tribes and nonprofit organizations carry out needs assessments similarly to the assessment required for all states. The statewide needs assessments have three purposes:

1. Identify communities with concentrations of: premature birth, low-birth weight infants, and infant mortality, including infant death due to neglect or other indicators of at-risk prenatal, maternal, newborn, or child health; poverty; crime; domestic violence; high school dropouts; substance abuse; unemployment; or child maltreatment. 2. Determine the quality and capacity of existing programs or initiatives for early childhood home visitation in the jurisdiction, including the number and types of individuals and families who are receiving services under such programs or initiatives; gaps in early childhood home visitation in the jurisdiction; and the extent to which such programs and initiatives are meeting the needs of eligible families. 3. Determine the state's capacity for providing substance abuse treatment and counseling services to individuals and families in need of such treatment or services.

Coordination with Other Assessments

In carrying out the needs assessment, jurisdictions must coordinate with, and take into account, other appropriate needs assessments conducted by the state, as determined by the HHS Secretary, including similar assessments already required under law: (1) the needs assessment for the Maternal and Child Health Services Block Grant (both the most recent completed assessment and any assessments in progress); (2) the community strategic planning and needs assessment under the Head Start program; and (3) the inventory of current unmet needs and current community-based and prevention-focused programs and activities to prevent child abuse and neglect and other family resource services under the Child Abuse Prevention and Treatment Act (CAPTA). HHS guidance issued in August 2010 also specified that the assessment should be coordinated with the state advisory council established under the Head Start Act (for children from birth to school entry); the state's child care agency; the state's education agency; the state's agencies administering federal funds to prevent and respond to domestic violence (under the Family Violence Prevention and Services Act [FVPSA] and STOP grants authorized under the Violence Against Women Act [VAWA]); and the state child welfare agency (if this agency is not also administering programs under CAPTA). In addition, the guidance encouraged coordination with the state Individuals with Disabilities Act (IDEA) agency.

Initial Needs Assessment

As a condition of receiving funds under the Maternal and Child Health Services Block Grant for FY2011, each jurisdiction was required to submit the needs assessment by September 20, 2010 regardless of whether it intended to apply for a grant to provide home visiting services. The 50 states, the District of Columbia, and the territories submitted the assessment and subsequently received a portion of their FY2010 MIECHV funds if they applied for them. (The three states that did not ultimately apply for MIECHV funds, and whose MIECHV programs are now operated by nonprofit organizations, also submitted an assessment.) Jurisdictions that applied for a MIECHV grant (which included the remainder of the FY2010 funds) had to subsequently submit an updated state plan in 2011 that included a final designation of the at-risk communities, a more detailed needs assessment for the targeted communities, and a specific plan for home visiting services tailored to address those needs.

As part of the needs assessment, HHS directed states and territories to describe their understanding of the term "community" based on the unique structure and makeup of the state or territory. For example, "community" could be composed of zip codes, neighborhoods, or census tracts (in urban areas) or counties (for rural areas). HHS defined "at-risk community" as a community for which indicators, in comparison to statewide indicators, demonstrate that the community is at greater risk than the state (or jurisdiction) as a whole. States and territories had the option of targeting all at-risk communities or sub-communities or neighborhoods deemed to be at greatest risk, if data on these smaller units were available. Jurisdictions were required to provide a justification for each such community identified, using the most recent and/or relevant data available on each of the risk factors (defined further in the guidance), for both the entire jurisdiction and each community defined as at risk.

Tribal grantees are required to conduct a needs assessment of the tribal community and to develop a plan to address those needs. The assessment is to be conducted within the first year of receiving funding under the program.

Update to Needs Assessment

With enactment of BBA 2018, jurisdictions (including tribal grantees and nonprofit organizations that operate home visiting programs in three states) must review and update their prior assessments. As with the initial assessment, the updated assessments must be coordinated with the statewide needs assessment required under the Maternal and Child Health Services Block Grant, but they may be conducted separately. The assessment must be reviewed and updated by the jurisdiction no later than October 1, 2020. In guidance, HHS has directed jurisdictions to begin activities related to the needs assessment update no earlier than January 2019 and to complete the assessment between early 2019 and October 1, 2020. The guidance notes that further information about the needs assessment is forthcoming.

How Jurisdictions Demonstrate Improvement

The MIECHV law requires states and other jurisdictions that receive grant funds for home visiting programs to demonstrate improvements among eligible families in what the law refers to as six "benchmark areas" (HHS sometimes calls benchmark areas "outcomes"). These six benchmark areas are desired outcomes for participants; for each of those outcomes, a state or jurisdiction operating a MIECHV program must establish a baseline to begin measuring performance (see Table 3 ). Jurisdictions were required to demonstrate improvements against these baselines within three years of the law's enactment. In addition, BBA 2018 directs jurisdictions to demonstrate improvements by the end of FY2020 (September 30, 2020) and every three years thereafter. HHS uses 19 items (described as "constructs") to measure the performance of each jurisdiction. Each benchmark area has between one and six constructs. This is a change from the performance accountability system that was in place through FY2016, when HHS used 37 constructs to measure performance. Under this prior system, jurisdictions were given flexibility in developing how they would measure performance for each construct. For example, all grantees had to measure prenatal care under the benchmark area for improved maternal and newborn health; however, grantees could focus on different aspects of performance, such as the onset of prenatal care or the adequacy of prenatal care. The revised performance measurement system requires grantees to measure performance under each construct in the same way. According to HHS, the revised data collection efforts are intended to make it easier for data to be aggregated nationally.

This data collection effort is focused on grantee performance over time rather than on the impacts of the program. As discussed in a subsequent section, HHS is assessing the effects of MIECHV programs through a separate evaluation effort.

Demonstrating Improvements After Three Years

The law required jurisdictions to show that they were making improvements in at least four of six benchmark areas three years after the law was implemented. The law also separately required jurisdictions to submit a report to HHS no later than December 31, 2015, about whether improvements were made in each of the benchmark areas.

By October 30, 2014, all states and territories operating a MIECHV program submitted reports to demonstrate their performance against the benchmarks for the first three years of the program. The tribal entities that were awarded funding under the first cohort of the tribal grants were required to submit their reports by December 31, 2014, and they did so. The three nonprofit organizations that operate programs in Florida, North Dakota, and Wyoming and were awarded funding after September 2011 were required to submit reports on the three-year benchmarks by October 30, 2016, and they did so.

If a jurisdiction fails to demonstrate improvements in at least half of the constructs in four of the benchmark (outcome) areas, it has to develop and implement a plan to make improvements in each of the applicable areas, subject to approval by HHS. HHS provides technical assistance to the grantee in developing and implementing the plan. As directed by statute, HHS convened an advisory panel made up of staff from HHS and the Department of Education to make recommendations about this technical assistance. The law requires HHS to terminate a jurisdiction's MIECHV funding if, after a period of time specified by HHS, the jurisdiction has failed to demonstrate any improvements in outcomes, or if HHS determines that the jurisdiction has failed to submit the required report on performance in benchmark areas. To date, one grantee (from the first cohort of tribal grantees) was not awarded funds due to performance and compliance concerns. No jurisdictions are currently on improvement plans.

Demonstrating Continuous Improvements

Jurisdictions must continue to track improvements in the benchmark areas. They must report to HHS about the benchmarks at least 30 days after the end of FY2020 and every three years thereafter. They must demonstrate that their program results in improvements for eligible families in at least four of the benchmark areas that are applicable to the home visiting models used by the jurisdiction . (Some models may not focus their activities on each of the benchmark areas.) This is distinct from the reporting on the benchmark areas for the initial three years, which did not specifically reference the benchmark areas that are applicable to the models. Further, jurisdictions must demonstrate improvements in the benchmark areas based on comparing enrolled families to families that did not receive services under a home visiting program. This varies from the initial reporting on benchmark data, which was based on improvements over time among enrolled families only.

As with the benchmark reporting requirement for the initial three years of the program, jurisdictions that do not show improvement within each subsequent three-year period must develop and implement a plan to improve outcomes that are subject to approval by the HHS Secretary. The improvement plan must include the same provisions that had been required as part of the initial reporting on benchmark data. HHS must continue providing technical assistance to the eligible entity in developing and implementing the improvement plan (but the law does not address the ongoing role of the advisory panel). HHS may opt to terminate the jurisdiction's grant if improvements are not made after a period specified by HHS, and provide remaining funds to nonprofit organizations to operate the home visiting program in that jurisdiction.

Additional Requirements

The law also specifies other requirements for jurisdictions carrying out MIECHV programs. Jurisdictions are to conduct individualized assessments of the families and to make improvements in particular outcomes that are relevant to each participating family. Such desired individual family outcomes are nearly identical to the benchmark areas, except that the outcomes also include improvements in parenting skills and in cognitive, language, social-emotional, and physical developmental indicators.

Jurisdictions must also ensure that the program

adheres to a clear, consistent home visiting model that meets the requirements for being research-based (discussed further in the next section) and is linked to the benchmark areas and outcomes for individual families; employs well-trained and competent staff, as demonstrated by education or training (such as nurses, social workers, educators, and child development specialists) and provides ongoing and specific training on the home visiting model; maintains high-quality supervision to establish "home visitor competencies"; demonstrates strong organizational capacity to implement the activities involved; establishes appropriate linkages and referral networks to other community resources and supports for eligible families; and monitors how the home visiting model is implemented to ensure that services are implemented with fidelity to the model.

Jurisdictions may use MIECHV funding to supplement, and not supplant, funds from other sources for early childhood home visitation programs or initiatives. Finally, as discussed in the next section, jurisdictions must spend most of their MIECHV funds on specified home visiting models that meet certain standards of effectiveness.

Home Visiting Models

Jurisdictions must use at least 75% of their total funding (regardless of whether they are formula or competitive funds) within a given fiscal year to carry out home visiting models that are "evidence-based." As outlined in the statute, models are evidence-based if they

have been in existence for at least three years; are associated with a national organization or institution of higher education that has comprehensive standards to ensure that services are high-quality and that the program continuously makes improvements; are research-based and grounded in relevant empirically-based knowledge; and have demonstrated significant positive outcomes in the benchmark areas and the desired individual family outcomes when evaluated using well-designed and rigorous quasi-experimental research designs or randomized controlled research design in which the evaluation results have been published in peer-reviewed journals.

In implementing the MIECHV program, HHS established criteria for determining which home visiting models have evidence of effectiveness after seeking public comment on the criteria (as required under the law). The criteria expand on the requirements in the law about models that are linked to specified outcomes and demonstrate significant positive outcomes. The criteria are as follows:

at least one high- or moderate-quality impact study of the model finds favorable, statistically significant impacts in two or more of eight outcome domains; or at least two high- or moderate-quality impact studies of the model using nonoverlapping study samples find one or more favorable, statistically significant impacts in the same outcome domain.

In this context, impact studies evaluate whether the home visiting model results in favorable outcomes for participants generally. As specified by HHS (and in accordance with the MIECHV law), the outcome domains are generally consistent with the benchmark areas and individual family outcomes for the program: (1) maternal health; (2) child health; (3) child development and school readiness; (4) positive parenting practices; (5) family economic self-sufficiency; (6) reductions in child maltreatment; (7) reductions in juvenile delinquency, family violence, and crime; and (8) linkages and referrals.

Jurisdictions may use up to 25% of their formula and/or competitively awarded funds for administering home visiting models that conform to a promising and new approach for achieving improved outcomes under the benchmark areas and improved family outcomes. The law specifies that such a "promising" model must have been developed or identified by a national organization or institution of higher education and will be evaluated through a well-designed and rigorous process led by the jurisdiction. HHS has further explained that a promising approach is one that meets the standards outlined in the statute but for which there is little to no evidence of effectiveness; one with evidence that does not meet the criteria for an evidence-based model; or a modified version of an evidence-based model that includes significant alterations to core components.

Home Visiting Evidence of Effectiveness (HomVEE)

In 2009, prior to implementation of ACA, HHS/ACF created the Home Visiting Evidence of Effectiveness (HomVEE) initiative to determine which home visiting models have shown evidence of effectiveness. The project has been incorporated into the MIECHV program. It annually (on a fiscal year basis) reviews the research literature on studies of models in which home visiting is the primary service strategy for pregnant women or families with children from birth to age five.

HomVEE prioritizes the home visiting models for further study based on a point system. Points are assigned to models based on the number and design of their impact studies (with three points for each randomized control trial (RCT) and two points for each quasi-experimental designed study) and their sample size of their impact studies (with one point for each study with a sample size of 250 or more). In addition, HomVEE reviewers determine whether the program is currently in operation and if additional information on the model can be gleaned from websites and others sources.

Of those models that receive sufficient points for further review, HomVEE examines applicable impact studies with RCTs and quasi-experimental designs, and assigns each study a rating of high, moderate, or low quality. After reviewing studies for a model, HomVEE evaluates the evidence across all studies that receive a high or moderate rating and measure outcomes in at least one of the eight domains. The reviewers additionally examine and report on other aspects of the evidence for each model, based on all high- and moderate-quality studies available.

Eighteen Models Found to be Evidence-Based as of June 2017

As of June 2017, the HomVEE review had identified 45 home visiting models as suitable for review and identified 18 of these models as having met the criteria for an evidence-based program. The HomVEE project also reviewed home visiting models to examine specific impacts for American Indian and Alaska Native populations. One model, Family Spirit, had such impacts and is one of the 18 models that meet the HHS criteria.

Selected Characteristics of the Models

HHS determined that each of the 18 models is effective in at least two of the eight areas that were included in the HHS criteria for evidence of effectiveness of home visiting models. Some key characteristics of the models are as follows:

Just over half of the models (11) target at-risk pregnant women, and all of them target parents and their young children. All but two models serve families with children under age one, and nearly all (14) serve children across multiple age ranges (birth to 23 months, 24 to 48 months, etc.). The models are implemented by a variety of entities that includes nonprofit and community-based organizations; hospitals, health clinics, or physicians; a state governmental agency (e.g., child welfare or health care agency); Head Start agencies; and other types of entities (e.g., preschool and criminal justice programs). All but four of the models require home visitors to meet certain minimum educational requirements. Home visitors are typically registered nurses, mental health professionals, social workers, or paraprofessionals.

Further, each model requires preplacement training on the model, and the majority of the models (14 models) require ongoing training, as opposed to having voluntary ongoing training (4 models). The caseload for home visitors varies, with a range of about 10 to 30 cases per worker (for 12 of the models); however, some models assign greater or fewer caseloads based on the needs of families. Many of the models call for weekly visits with the family for an initial period of time, and the visits often become less frequent over time. A few models specify a particular number of visits overall (ranging from 1 to 52 visits), and others provide a certain number of visits based on family needs. Four models provide additional types of interventions that include classes on preparing for motherhood and meetings with other program participants. See Table D-1 and Table D-2 for further detail on the characteristics of the 18 models designated as effective.

Use of Models

Table 4 summarizes information on the number of jurisdictions implementing each evidence-based model in FY2017. In addition, three jurisdictions (Arkansas, Kansas, and Tennessee) used a portion of their funds to implement a home visiting model in FY2017 that was promising, but not yet determined to be effective. Specifically, these states used 25% or less of their FY2017 formula grant allocation for this purpose.

Option to Fund Home Visiting Services on a Pay-for-Outcome Basis

The most recent law to reauthorize the MIECHV program, BBA 2018, added new language to enable a jurisdiction to use up to 25% of its MIECHV grants for a "pay-for-outcome" (sometimes referred to in policy literature as "pay-for-success") initiative that satisfies the requirements for providing evidence-based home visiting services. Funding for pay-for-outcomes initiatives may be expended by the eligible entity for up to 10 years after the funds are made available.

"Pay-for-outcome" initiative is defined as a performance-based grant, contract, or cooperative agreement awarded by a jurisdiction in which a commitment is made to pay for improved outcomes that result in social benefit and direct cost savings or cost avoidance to the public sector. Such an initiative is to include

a feasibility study that describes how the proposed intervention is based on evidence of effectiveness; a rigorous third-party evaluation that uses experimental or quasi-experimental design, or other research methodologies, that allow for the strongest possible causal inferences to determine whether the initiative has met its proposed outcomes; an annual, publicly available report on the progress of the initiative; and a requirement that payments are made to the recipient of a grant, contract, or cooperative agreement only when agreed-upon outcomes are achieved, except that this requirement does not apply to payments for the third-party evaluation.

HHS has provided some preliminary guidance to states advising that FY2018 formula funds are not to be used for pay-for-outcome initiatives; however, jurisdictions that plan to use future funding for this purpose must submit a letter of intent with a description of any past or current activities that would support pay-for-outcome initiatives, such as a feasibility study, third party evaluation, and outcome payments. This preliminary guidance noted that further guidance is forthcoming.

Technical Assistance

The law directs the HHS Secretary to provide technical assistance (TA) to grantees, specifically with regard to administering programs or activities that are funded by the MIECHV program. In addition, HHS is to provide technical assistance to any jurisdiction that is required to implement an improvement plan because it failed to improve in the benchmark (or outcome) areas. Jurisdictions receive TA from federal staff, developers of home visiting models, and TA providers contracted with HHS. Multiple HHS-contracted providers assist grantees.

HRSA provides assistance to grantees through the MIECHV Home Visiting-Improvement Action Center (HV-ImpACT), which is operated under a contract with the Education Development Center, a national nonprofit organization that provides support to states and territories in implementing and improving their programs. HV-ImpACT provides training and technical assistance that focuses on administering high-quality programs, strengthening coordination of early childhood systems, and improving program outcomes. ACF provides similar types of technical assistance to Tribal MIECHV grantees via Programmatic Assistance for Tribal Home Visiting (PATH), operated by Zero to Three, a national nonprofit organization.

ACF also provides assistance to grantees through the Design Options for Maternal, Infant, and Early Childhood Home Visiting Evaluation (DOHVE) Technical Assistance Team. James Bell Associates operates the DOHVE Technical Assistance Team. DOHVE provides technical assistance to jurisdictions on their research and evaluation efforts. For example, they assist jurisdictions with developing meaningful plans to evaluate home visiting programs and disseminate findings, building capacity to analyze returns on investments in home visiting, integrating home visiting data into other early childhood data systems, and coordinating state and tribal home visiting efforts. Tribal entities receive technical assistance on these same topics via the Tribal Evaluation Institute (TEI) . James Bell Associates operates TEI.

Research and Evaluation

The law directs the HHS Secretary to carry out a continuous program of research and evaluation activities to increase knowledge about home visiting programs, using random assignment designs when feasible. In practice, these activities include developing studies of home visiting models and sharing research and best practices. In addition, HHS requires jurisdictions to conduct evaluations of home visiting programs if they are implementing promising models (as opposed to a model that HHS has determined is evidence-based) or receive competitive awards.

National Evaluation of MIECHV: MIHOPE

The HHS Secretary was required to appoint an independent advisory committee of experts in program evaluation and research, education, and early childhood development. The purpose of this panel is to review, and make recommendations, on the design and plan for a national evaluation of the MIECHV program. HHS appointed the panel in 2013. As specified in the law, the evaluation must include an

analysis of the results of the statewide needs assessments and state actions in response to the assessments; assessment of the effect of early childhood home visitation programs on child and parent outcomes, including with respect to the benchmark areas and the individual family outcomes (described previously); assessment of the effectiveness of home visiting programs on different populations, including the extent to which the ability of programs to improve participant outcomes varies across programs and populations; and assessment of the potential for the activities carried out under home visiting programs, if scaled broadly, to improve health care practices, health care system quality, and efficiencies; eliminate health disparities; and reduce costs.

The evaluation, known as the Mother and Infant Home Visiting Program Evaluation (MIHOPE), is examining programs that use the four most common evidence-based home visiting models: Early Head Start-Home Visiting (EHS), Healthy Families America (HFA), Nurse-Family Partnership (NFP), and Parents as Teachers (PAT). The MIHOPE study includes 4,229 families in 88 local home visiting programs across 12 states who were randomly assigned to receive home visiting services or to a control group that was referred to non-home visiting services available in the community. The evaluation is generally designed to address the requirements outlined in the law and will include (1) an analysis of state needs assessments, (2) an implementation study of local program services, (3) an impact analysis of the effects of MIECHV on child and family outcomes, and (4) an economic analysis of program costs and cost effectiveness. MDRC, the social policy research organization, is conducting the evaluation, along with partner organizations.

MIHOPE researchers collected information from families when the mother was pregnant or the child was no more than six months, and again when the child was 15 months old and between the ages of 2 ½ and 3 ½ years. HHS published a report on the implementation study, and additional reports are forthcoming.

The implementation study reported that families participated in the home visiting program for an average of eight months in the year following their first visit, and about half of all families were participating at the time of the child's first birthday. Families with more challenges and barriers participated in home visiting programs for shorter periods compared with average families in the study. Families in programs implementing EHS or NFP stayed in the program longer. About half of all families received at least one referral for public assistance or health insurance, including public health insurance programs. On average, families and home visitors discussed five topics in each visit; the most common topics discussed were mental health, positive parenting behavior, child preventative care, child development, and economic self-sufficiency. Home visitors described their role as providing consistent and stable support to empower mothers in their role as their child's first teacher. Some home visitors reported that they had challenges identifying and addressing a mother's poor mental health, substance abuse, and intimate partner violence.

In 2016, HHS awarded a separate contract to MDRC to design a follow-up study of MIHOPE participants. This evaluation is known as MIHOPE-LT (long term), and is designed to track outcomes of families in the study when their children are in kindergarten, third grade, early adolescence, and late adolescence. The evaluation is to include a cost-benefit analysis to examine whether benefits to families outweigh the costs of the four home visiting models.

MIHOPE-Strong Start Evaluation

In addition to the MIHOPE evaluation, the MIHOPE expansion evaluation (MIHOPE-Strong Start) is examining birth and health outcomes for mothers and infants through the Strong Start for Mothers and Newborns (Strong Start) initiative. Strong Start is carried out by the Centers for Medicare and Medicaid (CMS). The initiative is examining whether nonmedical prenatal interventions, when provided in addition to routine medical care, can improve health outcomes for pregnant women and newborns and decrease the cost of medical care during pregnancy, delivery, and over the course of the child's first year of life. One of those interventions is home visiting.

The MIHOPE-Strong Start evaluation seeks to determine whether home visiting services can impact health outcomes for disadvantaged pregnant women. The evaluation enrolled approximately 3,000 families from Healthy Families America and Nurse-Family Partnership sites in 66 local home visiting programs in 17 states. Families were randomly assigned to a home visiting group or to a non-home visiting control group. Participants include pregnant women who have Medicaid or CHIP (Children's Health Insurance Program) and are interested in and eligible for home visiting services, along with their children. The evaluation includes an implementation study and an impact analysis of the outcomes in three areas: (1) birth outcomes, (2) maternal prenatal health and health care use, and (3) infant health and health care use. The evaluation is also intended to provide information relevant to CMS on how participation in such programs might affect Medicaid costs. The evaluation was designed by CMS and ACF, is funded by CMS (without MIECHV funds), and is implemented in partnership with HRSA.

HHS has published a report that provides an overview of how the 17 states involved in the MIHOPE evaluation are working to promote prenatal and positive birth outcomes. The report discusses the major stakeholders and partners involved in supporting these outcomes, through such efforts as providing funding, administering and expanding programs, supporting system-building efforts, linking services to families, and conducting training and professional development. The report also identified that the states use multiple sources to fund home visiting and other resources to support positive prenatal and birth outcomes. Additional reports for MIHOPE-Strong Start are forthcoming.

Grantee-Led Evaluations

As noted, jurisdictions conduct evaluations of home visiting programs if they are implementing promising models. They also have the option to conduct evaluations of models that HHS has determined to be evidence-based, particularly for enhancements to these models. Plans for these evaluations must first be approved by HHS. Between 2011 and 2015, 48 jurisdictions developed grantee-led evaluations for promising approaches and evidence-based models. Based on an analysis by HHS, these grantee-led evaluations have helped to identify how programs are carried out, including (1) how to recruit, retain, and engage participants; (2) how to develop the home visiting workforce; (3) how to collaborate with community partners and coordinate services; (4) how programs are enhancing home visiting; and (5) the effectiveness of promising approaches in home visiting.

Other Research and Evaluation Activities

HHS supports efforts to learn more about selected aspects of home visiting, such as mapping the career trajectories of home visitors and investigating how home visiting programs can support families in substance abuse prevention, treatment, and recovery. In addition, HRSA and ACF support collaborative efforts that focus on certain research topic s:

HRSA contracts with Johns Hopkins University to operate the Home Visiting Applied Research Collaborative (HARC). The center provides funding to researchers to strengthen home visiting practices. It also partners with other academic institutions, research firms, and home visiting experts to design and build HARC's research agenda. HRSA provides funding to the Education Development Center to operate the Home Visiting Collaborative Improvement and Innovation Network (HV-CoIIN 2.0) . This network convenes teams from states and local home visiting agencies to focus on improving home visiting interventions that were found to be effective in the earlier collaborative network known as HV-CoIIN 1.0. These issues include screenings for maternal depression, access to treatment, reducing symptoms, early detection, and linkages to services for children at developmental risk. HV-CoIIN 2.0 will also build capacity to improve in other areas, such as screening and referrals for intimate partner violence. ACF provides MIECHV funding to the Tribal Early Childhood Research Center (TRC). The center also receives funding from the HHS-funded Head Start and Child Care programs. The TRC seeks to partner with American Indian and Alaska Native communities, programs, practitioners, and researchers to advance research into early childhood development and early childhood programs for American Indian and Alaska Native children and families. The TRC is located at the University of Colorado Denver's School of Public Health.

Recent Congressional and Executive Branch Action

Since 2014, Congress has held oversight hearings on the MIECHV program and considered legislation to extend funding for and reauthorize it. The program was reauthorized through FY2022 under the Bipartisan Budget Act of 2018 in February 2018.

On January 9, 2014, the House Energy and Commerce Committee held a hearing on the extension of health care policies that included discussion of the MIECHV program. Two witnesses from HHS testified about how the MIECHV program has been carried out and on the screening and use of evidence-based models selected by jurisdictions in the program. On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014 ( P.L. 113-93 ), which extended funding for the MIECHV program through March 31, 2015 (the law also extended funding for other health care programs and policies). On April 2, 2014, the House Ways and Means Subcommittee on Human Resources held a hearing on the MIECHV program. Witnesses included a home visiting nurse and her client, an administrator of a home visiting program, and two researchers. They discussed how the program works in practice, both from the perspectives of program staff and the client. In addition, researchers discussed the current research on home visiting, including the efficacy of selected home visiting models. On March 15, 2017, the Subcommittee on Human Resources held another hearing that focused on reauthorization of the program, including testimony from staff and a client with a national home visiting model, a home visiting manager, and a state committee in Illinois that promotes home visiting services. Witnesses generally discussed the benefits of home visiting.

As mentioned, the Protecting Access to Medicare Act of 2014 ( P.L. 113-93 ) was signed into law on April 1, 2014, and provided funding of $400 million for the first half of FY2015 (October 1, 2014, through March 31, 2015). The Medicare Access and CHIP Reauthorization Act of 2015 ( P.L. 114-10 ), signed into law on April 16, 2015, extended the $400 million made available under P.L. 113-93 through all of FY2015 (October 1, 2014, through September 30, 2015). P.L. 114-10 also provided $400 million for each of FY2016 and FY2017 under the program.

On June 8, 2017, the Increasing Opportunity through Evidence-Based Home Visiting Act ( H.R. 2824 ) was introduced and referred to the House Ways and Means Committee and the House Energy and Commerce Committee. The bill sought to reauthorize, and make substantive changes to, the MIECHV program. At a September 13, 2017, markup, the Ways and Means Committee considered amendments to H.R. 2824 . The committee reported the bill, as amended. On September 26, 2017, the House passed H.R. 2824 with additional amendments. On September 19, 2017, the Strong Families Act of 2017 ( S. 1829 ) was introduced, and included several of the same provisions in H.R. 2824 . The Bipartisan Budget Act of 2018 ( H.R. 1892 ), enacted on February 9, 2018 as P.L. 115-123 , incorporated all of S. 1829 and a provision in H.R. 2824 that directs HHS to use the most accurate relative federal population and poverty data if HHS awards funds based on these factors.

Appendix A. Legislative History of Home Visiting

Federal Efforts to Establish a Home Visiting Program

Congressional and executive branch interest in early childhood home visiting programs predated the Affordable Care Act and implementation of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Since 2004, Congress has considered home visiting legislation and held related hearings across multiple committees. Some of these efforts have supported selected home visiting models and/or particular aspects of home visiting, such as its role in promoting parent and child education, responding to domestic violence, and reducing child maltreatment. Some home visiting proposals reflected government-wide efforts beginning in the George W. Bush Administration and extending into the Obama Administration to expand social programs that work and eliminate those that do not.

Education Begins At Home Act

The Education Begins at Home Act ( S. 2412 ; 108 th Congress), introduced in 2004, sought to authorize a stand-alone home visiting program, and would have directed the Departments of Education and Health and Human Services to collaboratively award grants to support home visiting. It would have also amended the Early Head Start program to establish standards for home visiting staff. The bill was not taken up; however, several similar bills were introduced in subsequent years. One of these similar bills (the Education Begins At Home Act, H.R. 3628 ; 109 th Congress) was the focus of a hearing by the House Education and the Workforce Committee. At the hearing, Representative Osborne said that home visiting can "deliver parent education and family support services directly to parents with young children and aim to offer guidance to parents on how to support their children's development from birth through their enrollment in kindergarten." Other witnesses, including representatives from two home visiting programs (Parents as Teachers and Nurse-Family Partnership), testified about the role of home visiting in improving multiple child and family outcomes in education, health, and other domains.

Home Visiting and Domestic Violence Program

In 2006, the Violence Against Women and Department of Justice Reauthorization Act of 2005 ( P.L. 109-162 ) was signed into law. It authorized $7.0 million each fiscal year for FY2007-FY2011 for the Department of Justice to develop and implement policies and procedures to help home visitors address the effect of domestic violence on pregnant women as well as young children and their parents. Congress did not appropriate funds for the program, and the Violence Against Women Reauthorization Act of 2013 ( P.L. 113-4 ) repealed the authorizing language.

Supporting Evidence-Based Home Visiting to Prevent Child Maltreatment

Congress subsequently funded a home visiting pilot program that had been proposed by the Bush Administration in the FY2008 budget request and had a child maltreatment focus. As part of the request, the Administration sought $10 million (as a set-aside within the discretionary activities account of the Child Abuse Prevention and Treatment Act, CAPTA) for competitive grants to expand, upgrade, or develop home visiting programs that have "proven effective models," and to support a national cross-site evaluation to examine factors associated with successful replication or expansion of such models. To support this initiative, Congress provided $10 million in FY2008 and $13.5 million in FY2009 as a set-aside from the CAPTA discretionary activities account. Funding in years 3 through 5 of the initiative was provided under MIECHV.

This initiative—Supporting Evidence-Based Home Visiting to Prevent Child Maltreatment (EBHV)—was carried out by ACF, which awarded cooperative agreements to 17 grantees (mostly private, nonprofit organizations; state or local agencies; or hospitals or medical centers) in 15 states. The goals of the initiative were to (1) support implementation with fidelity to home visiting program models; (2) help scale up home visiting models, by replicating the program in a new area, adapting the model for a new population, or increasing enrollment capacity in an existing service area; and (3) help sustain the home visiting model beyond the end of the grant period. EBHV funding was not used to cover the full cost of direct home visiting services; instead, grantees used other funding sources for such services. Grantees were expected to adopt home visiting models that, as defined by ACF, were evidence-based programs.

Each grantee worked with one or more implementing agencies to deliver home visiting services to families or served as the agency and provided services directly. The implementing agencies used one or more of the following five models in carrying out home visiting services: Healthy Families America, Nurse-Family Partnership (NFP), Parents as Teachers (PAT), SafeCare, and Triple P. In addition to the cooperative agreements, ACF awarded funds to Mathematica Policy Research, Inc., and the Chapin Hall Center for Children to conduct a cross-site evaluation of the funded programs.

The evaluation found that the grantees generally adhered to standards that measured fidelity to a home visiting model; however, they often struggled to maintain caseloads and deliver services as intended. In addition, the grantees participated in activities to build infrastructure and partnerships. Such activities included strengthening fiscal capacity through partnering and fundraising, building community awareness or political support for programs, and evaluating and monitoring programs. The evaluation found that grantees with greater investment in these activities tended to achieve the initiative's goals.

While the EBHV initiative was underway, the Obama Administration proposed a new capped entitlement program as part of its FY2010 budget request for grants to states, territories, and tribes to establish and expand evidence-based home visitation programs for low-income mothers and pregnant women. The program was intended to "create long-term positive impacts for children and their families, as well as generate long-term positive impacts for society as a whole." Under the proposal, the Administration sought to give priority to funding for home visiting models "that have been rigorously evaluated and shown to have positive effects on critical outcomes for families and children." The proposal also included provisions to ensure that states and other jurisdictions would adhere to a proven program model and sought to direct some of this funding for technical assistance and program assessment and monitoring. The Administration requested $124 million for an initial year of the program and envisioned a "gradual growth" in the program so that it would reach an estimated 450,000 new families at a cost of $1.8 billion over a 10-year period.

Home Visiting as Part of Health Care Reform

At the same time that Congress was considering whether to fund the Obama Administration's initiative, other home visiting proposals were moving forward in the House and the Senate. In June 2009, the House Ways and Means Subcommittee on Income Security and Family Support held a hearing on early childhood home visitation programs, related research, and a bill introduced by members of the subcommittee ( H.R. 2667 ) to establish a home visiting program. Witnesses included researchers, an administrator of state-funded home visitation programs, a former participant and current home visitor, and a nurse consultant. The witnesses generally supported broader implementation of early childhood home visiting models with a proven record of positive outcomes for families based on rigorous research.

In November 2009, the House passed the Affordable Health Care for America Act ( H.R. 3962 ). The bill included two home visiting provisions. Section 1713 specified that the Medicaid program support home visits by trained nurses. This section appeared to draw from the Healthy Children and Families Act of 2007 ( H.R. 3024 / S. 1052 ). Section 1904 sought to provide a program for home visiting, to be funded at $750 million over five years (FY2010-FY2014). This section appears to have been drawn primarily from H.R. 2667 , which had been introduced earlier in 2009. Separate health care reform efforts in the Senate culminated in the passage of the Patient Protection and Affordable Care Act ( H.R. 3590 ) on December 24, 2009; the bill included the MIECHV program. H.R. 3590 was taken up by the House on March 21, 2010, and was signed into law on March 23, 2010, as P.L. 111-148 .

HHS first allocated funding for the MIECHV program in FY2010. As the MIECHV program was implemented, the EBHV grantees entered into subcontracts with the MIECHV lead agency in their states, and these states received additional funds from FY2010 through FY2012 to pass through to EBHV grantees. Some of the EBHV grantees received MIECHV funds to allow them to sustain services beyond the EBHV funding period or to expand services. However, some grantees were using models that did not meet HHS criteria under the MIECHV program for being effective and therefore were ineligible for funding.

Appendix B. MIECHV Formula Funding by State and Territory

Appendix C. Timeline for the MIECHV Program

Appendix D. Home Visiting Models Used Under the MIECHV Program